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Enferm Clin. 2019;xxx(xx):xxx---xxx

www.elsevier.es/enfermeriaclinica

Effective orientation programs for new graduate

nurses: A systematic review夽
Retno Indah Pertiwi, Rr. Tutik Sri Hariyati ∗

Faculty of Nursing, Universitas Indonesia, Depok, West Java, Indonesia

Received 13 November 2018; accepted 17 April 2019

KEYWORDS Abstract
Newly graduated Objective: To determine the most effective orientation program for new graduate nurses (NGNs)
nurse; in hospital settings.
Nurse orientation Method: A systematic review of existing literature was conducted following a search of the elec-
program; tronic databases Science Direct, PubMed, EBSCOhost, ProQuest, and Wiley Online (2008---2018).
Nurse transition Searches utilized the following keywords nurse orientation, new nurse orientation, practical
program orientation, nurse transition, and nurse transition program.
Results: A total of fourteen studies met our review criteria. Evidence from these studies showed
that current orientation protocols consist of preceptorship, classes, and simulations of patient
care. The most efficacious orientations had well-established goals and utilized proven learn-
ing materials, support systems such as preceptorship and mentorship, learning methods, and
evaluation instruments within the organization.
Conclusion: Well-designed orientation programs will result in positive effects on NGNs and
patient care in the hospital.
© 2019 Elsevier España, S.L.U. All rights reserved.

Introduction lenged as they adjust themselves to their new profession

and organization.1 Existing literature outlines several stres-
Newly graduated nurses (NGNs) undergo a difficult tran- sors on NGNs including waiting for National Council Licensure
sition period from student to professional nurse following Examination (NCLEX) results, moving away from home to live
graduation. NGNs are both mentally and emotionally chal- independently, and adjusting to the new demands of their
work environment.2 All of these new responsibilities often
produce stress and anxiety.3
夽 Peer-review of abstracts of the articles is under the responsi- NGNs also face certain personal difficulties during the
bility of the Scientific Committee of Universitis Indonesia. Full-text transition period. Studies have shown that lack of confi-
and the content of it is under responsibility of authors of the article. dence, high workloads, orientation issues, fear, frustration,
∗ Corresponding author.
and being overwhelmed are frequent transition difficul-
E-mail address: [email protected] (Rr.T.S. Hariyati). ties for NGNs.2,3 These can lead to transition-precipitated

https://doi.org/10.1016/j.enfcli.2019.04.094
1130-8621/© 2019 Elsevier España, S.L.U. All rights reserved.

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systematic review. Enferm Clin. 2019. https://doi.org/10.1016/j.enfcli.2019.04.094
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2 R.I. Pertiwi, Rr.T.S. Hariyati

shock that must be recognized and addressed by nurses and sampling method.8 All studies covered implementation of
hospital management. A lack of management involvement an orientation program either developed by the study
in overcoming shock can lead to negative emotions4 that authors or based on existing theory and then assessed
can affect an NGNs’ intention to remain in nursing. Other the results thereof. Research designs varied, and included
hurdles include gaps in education, burnout, and negative pilot project,9---13 quasi-experimental,14,15 mixed method,8,16
experiences.5 non-experimental mixed method,17 cohort,18---20 and quasi-
Ideally, hospitals should be proactive when tackling these experimental pre-test/post-test.15
issues. Well-prepared orientation programs can help pre- Orientation program lengths ranged from six days to one
vent shock by helping NGNs to assimilate into their new year; one study did not report the length of the orientation
work environments and providing tools to help them adapt program investigated.10 Activities in these orientation
to their new workloads. Supportive orientation increases programs included preceptorship9---11,13---18,20,21 ; class-based
NGNs’ job satisfaction in the ward.6 Successful orienta- activities8---10,12,13,18,21 ; laboratory simulations10,12,13,18,21 ;
tion programs can go a long way toward overcoming the patient care simulations8,11,13---16,18,19,21 ; bedside learning8 ;
problem of transition shock in NGNs. Hospital support of and clinical practice days.10,16 Preceptorship and mentorship
NGNs throughout the full first year of practice can promote programs were carried out according to existing practice
the development of professional confidence.7 Despite this and modifications introduced by the given preceptor or
data, however, only 50.6% of nurses interviewed reported a mentor. One of the studies detailed collaboration with
structured orientation program at their hospitals.6 A review retired nurses referred to as VNAs (volunteer nurse ambas-
of existing orientation programs for NGNs could provide sadors) to act as additional mentors for the NGNs.12 Another
evidence-based strategies to improve NGN retention as well described the implementation of pathway orientation to
as the quality of nursing care. The study aims to determine help NGNs and their preceptor begin the preceptorship
the most effective orientation program for new graduate prior to the commencement of the orientation period.10
nurses (NGNs) in hospital settings. Class activities such as sharing journal assignments,11,16,21
peer group discussions,19 role-playing,21 and review of
materials provided by the hospital were parts of the
Method
orientations investigated for this review. Basic orien-
tation courses included human resources and nursing
Search strategy policies,10,17 environmental and safety culture,10,11,16
infection control,10 emergency procedures,10 conflict
This systematic review was conducted by gathering data resolution,18 incident reporting,18 stress management,18
from five databases, Science Direct, PubMed, EBSCO, Pro- professional development,20,21 service excellence,16 ethics,
Quest, and Wiley Online, from 2008 to 2018. Data collection quality,16 patient rights,16 and communication.16
was performed on studies gleaned from a search using the Learning materials were provided regarding the end
following keywords: nurse orientation, new nurse orien- of life care,20 therapy and blood transfusion policies,10
tation, practical orientation, nurse transition, and nurse use of medical equipment (such as fluid pumps),10 human
transition program (Table 1). Suitability was determined by organ systems and their relevant departments (e.g., cardi-
reviewing the title, abstract, and overall content, and four- ology, respiratory, neurology, hepatobiliary),11 sepsis,11 and
teen studies were aligned with our selected theme. Specific trauma.11 New technologies were implemented into certain
inclusion and exclusion criteria are detailed in Table 2. orientation programs, including a human patient simula-
®
tor called Laerdal Sim-Man ,15 computer-based learning,12,19
8
Selection of articles and online materials.
A variety of measuring tools were used to evaluate the
We employed an adapted PRISMA (Preferred Reporting Items orientation programs, including the Advisory Board’s Critical
for Systematic Reviews and Meta-Analyses) model; data Thinking Diagnostic,11 the New Graduated Nurse Learning
selection proceeded through four stages. The keyword Behavior Rating Guide14 , the Casey-Fink Graduate Nurse
search in the five databases yielded 3025 studies. The first Experience Survey,8,9,17,18,20,21 the Health Sciences Reasoning
step is the identification of the studies from five databases; TestTM (HSRT), the Clinical Decision-Making in Nursing Scale
the second step is exclusion stage was based on the title (CDMNS),15 and the Halfer-Graf Job/Work Environment
(n = 204); the third step is exclusion stage based on abstract Nursing Satisfaction Survey.16 Certain studies employed
(n = 77); and the fourth is exclusion stage on overall content instruments designed by the investigators to evaluate the
(n = 14). This process is described in Fig. 1. The analysis was orientation programs. Aspects evaluated were wide-ranging,
carried out specific to the orientation program for NGNs in including satisfaction,9,10,14,16,17 cost savings,10,13,18,19 time
the hospital using a narrative, descriptive method. effectiveness,10,19 critical thinking,11,15 retention and
turnover,9,12,14,16---21 performance,14 effectiveness,8,19
17,21
confidence, and engagement (Table 3).9,16,17
Results

Data search and selection was performed in fourteen stud- Discussion

ies corresponding to the inclusion criteria. The target
samples from those studies were NGNs with sample sizes Orientation time given to NGNs is a critical feature for anal-
ranging from three to 521. One of the studies did not ysis, as the length thereof can affect costs incurred and
specify sample size, and reported only use of a total results derived from the program. The shortest orienta-

Please cite this article in press as: Pertiwi RI, Hariyati RrTS. Effective orientation programs for new graduate nurses: A
systematic review. Enferm Clin. 2019. https://doi.org/10.1016/j.enfcli.2019.04.094
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Effective orientation programs for new graduate nurses 3

Table 1 A database search results.

Database Keywords N
Science ‘‘nurse orientation’’ 412
Direct ‘‘effective orientation’’ AND nurse
‘‘new nurse orientation’’
‘‘nurse orientation program’’
‘‘nurse transition’’
PubMed ‘‘nurse orientation’’ 34
‘‘effective orientation’’ AND nurse
‘‘new nurse orientation’’
‘‘nurse orientation program’’
‘‘nurse transition program’’
EBSCO ‘‘nurse orientation’’ 130
‘‘effective orientation’’ AND nurse
‘‘new nurse orientation’’
‘‘nurse orientation program’’
‘‘nurse transition’’
ProQuest ‘‘nurse orientation’’ 2,328
‘‘effective orientation’’ AND nurse
‘‘new nurse orientation’’
Willey ‘‘nurse orientation’’ 121
Online ‘‘effective orientation’’ AND nurse
‘‘nurse transition program’’
‘‘nurse transition’’
Total 3,025

Table 2 Inclusion and exclusion criteria.

Inclusion criteria Exclusion criteria
New graduated general New graduated specialist nurse
nurse from the Nurse practitioner
hospital Public health nurse
Nurse student
Orientation program in Orientation program in specialized units such
hospital as the operating room, ICU, emergency
department, etc.
Quasi Experimental Opinion/Discussion
Pilot Project Dissertation
Cohort Study

Search results from five databases (n = 3,025): Science

Direct (n = 412), PubMed (n = 34), EBSCO (n = 130),
Proquest (n = 2,328), Willey Online (n = 121) 2,821 studies were
excluded because they did
not meet the inclusion
criteria based on titles
Title screening
(n = 204)
127 studies were excluded
because they did not meet
the inclusion criteria based
Abstract screening on abstract
(n = 77)

Full screening
(n = 14)
63 studies were excluded
because they did not meet
the inclusion criteria based
on overall content

Figure 1 Data searching.

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systematic review. Enferm Clin. 2019. https://doi.org/10.1016/j.enfcli.2019.04.094
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systematic review. Enferm Clin. 2019. https://doi.org/10.1016/j.enfcli.2019.04.094
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Table 3 Description of included studies.

No Author/year Method Sample Measurement tool Length of orientation Program Result
1 Allen/2011 Pilot project 60 A self-designed tool • 8 hours for basic hospital • Preceptor Satisfaction: increase 1%
orientation • Orientation pathway Cost saving: $62,000
• 8 hours for nursing • Basic hospital Time-effectiveness: complete
orientation orientation one week earlier
• 4 hours for clinical lab • Nursing policies
• Continue with preceptorship • Clinical lab
(not stated)
2 Bittner/2016 Pilot project 24 Advisory Board’s Critical 400 hours • Simulation Critical thinking: improved at 6
Thinking Diagnostic • Learning activities and 12 months interval
• Reflective journaling
• FGD

ARTICLE IN PRESS
• Preceptorship
3 Roche/2013 Quasi 24 New Graduated Nurse Five weeks HPS simulation case for Satisfaction: 4.25 (Likert scale
experimental pilot Learning Behavior Rating the intervention group 1---5)
study Guide Preceptorship for both Retention: all participant still
group employed one year after hire
Performance: no significant
differences between
intervention and control group
4 Rush/2013 Mixed methods Not stated • Casey-Fink Graduate One year • Written materials Helpfulness: 57.6%
study Nurse Experience Survey • Classroom/theory
• Orientation to the • Simulation/theory
employer/nursing unit • Hands-on/bedside
• General transition learning
• The specific new • In service
graduate nurse transition programs/workshops
program • Website/online
materials
5 Maneval/2012 Quasi- 26 Health Sciences Ten weeks • Experimental: Critical thinking: pretest score
experimental: Reasoning TestTM (HSRT) Standard new nurse of 20.92 (SD = 3.43) compared
Pretest---posttest and the Clinical orientation, and six with a mean posttest score

R.I. Pertiwi, Rr.T.S. Hariyati

design Decision-Making in high-fidelity patient of 21.89 (SD = 2.52)
Nursing Scale (CDMNS) simulation experiences
with the Laerdal
®
Sim-Man , a fidelity
human patient simulator.
• Control: Standard new
nurse orientation
• Preceptorship for both
group
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Table 3 (Continued)
systematic review. Enferm Clin. 2019. https://doi.org/10.1016/j.enfcli.2019.04.094
Please cite this article in press as: Pertiwi RI, Hariyati RrTS. Effective orientation programs for new graduate nurses: A

No Author/year Method Sample Measurement tool Length of orientation Program Result

6 Hillman/2011 Cohort 251 Casey-Fink Graduate 16 weeks • Centralized class day Retention: 100%
Nurse Experience Survey • Unit-specific class day Cost saving: 4 million dollar
• Preceptorship Helpfulness: Yes
• Simulation lab
7 Murphy/2017 Cohort 521 A self-designed tool 6 days • Corporate orientation Turnover: 12.28%
• Computer training Cost saving: $156,000
• Experiential learning Time-effectiveness: shortened
8 hours/day
8 Olson- Non-experimental 31 Casey-Fink Graduate Three months • New employee Confidence: increase
Sitki/2012 mix method design Nurse Experience Survey onboarding and central in 12 months
nursing orientation Satisfaction: overall yes
• Unit-based orientation

ARTICLE IN PRESS
Engagement: highly engaged
• The nurse residency
program
9 Phillips/2014 Quasi- 4 Casey-Fink Graduate 12 months • Graduate Nurse Competency: improve at 6
experimental Nurse Experience Survey • Internship Program and 12 months
(GNIP) Retention: 11.5% better than
• Preceptorship control group
• Adult learning
10 Anderson/2009 Mix qualitative- 90 Halfer-Graf tool/Work One year • Interactive Nurse Satisfaction: yes
quantitative Environment Nursing Residency Engagement: yes
Satisfaction Survey • Preceptorship
• Peers
11 Baldwin/2016 Pilot project 3 A self-designed tool 18 weeks followed mentoring VNA (volunteered nurse Retention: 100%
for one year ambassador) from a
retired nurse
12 Horwarth/2016 Pilot project 5 A self-designed tool Eight weeks • A Collaborative Model Cost saving: over $19,000
• Preceptorship
• Simulation
13 Kowalski/2010 Cohort 55 • A self-designed tool One year • Nurse Residency Retention: 78%
• Pagana’s clinical stress Program
questionnaire • Preceptorship
• Spielberge’s state-trait
anxiety inventory
• Casey-Fink Graduate
Nurse Experience Survey
14 Maxwell/2014 Cohort 18 • Casey-Fink Graduate One year • UHC/AACN New Engagement: yes
Nurse Experience Survey Graduate Satisfaction: yes
• Graduate nurse • Nurse Residency Retention: before 40%,
residency program Program after 100%
evaluation • Preceptorship

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6 R.I. Pertiwi, Rr.T.S. Hariyati

tion time in the study was six days, while the longest was must be achieved. It is also essential to evaluate orienta-
twelve months. Comprehensive orientation processes cor- tion activities during the orientation process, by comparing
related significantly to the length of orientation22 ; research results with stated objectives. Hospitals can design their
suggests that the NGN orientation period should be at least evaluation instruments or use one that is already available.
four weeks long.23 All articles reviewed for this study met In studies analyzed for this review, four of the fourteen stud-
this guideline except for one, wherein the period was six ies used the Casey-Fink Graduate Nurse Experience Survey
days.19 in the evaluation process.8,9,17,18,20,21 Instruments that have
Most researchers reported a support system comprised of been tested for validity and reliability can help to ensure
a preceptor, classes, and simulations. Although the role of usable data.
the preceptor is challenging, many studies suggested that
a successful preceptorship can increase NGN job satisfac-
Conclusion
tion and retention of NGNs leading to decreased turnover.24
One successful support system included mentoring by a VNA;
Nursing managers should design and manage orientation pro-
NGNs reported high rates of satisfaction with the program.12
grams aligned with evidence-based research. Modifications
In this system, retired nurses are recruited to shadow the
can be made as necessary with regards to the hospital’s
NGNs while they provide nursing care to their patients. In
available budget and existing technology. Orientation length
addition to good mentorship, classes and simulations are
should be determined in accordance with orientation goals
also an essential part of the orientation process to provide a
and activities. Components of a successful orientation pro-
safe and productive learning environment. Research shows
gram are learning materials, support systems, and learning
that simulations of common clinical events in a group setting
methods with proven efficacy. Nursing managers must also
help NGNs to develop clinical reasoning and decision making
design measurable goals for the program and NGNs to enable
skills.25
evaluations in real time of orientation programs so managers
Classroom materials could be categorized into hospital
can make continuous improvements to existing systems.
and nursing policies, anatomical and physiological systems
reviews, and international accreditation standards, with the
goal of bringing theory into practice. Studies have inti- Conflict of interests
mated that NGNs feel underprepared for practice because
expectations of registered nurses are much greater than The authors declare no conflict of interest.
those of students, prioritization of care is difficult to put
into practice, and the workload can impede focus.26 Class-
room materials detailing the human body systems as they
Acknowledgments
relate to clinical practice help NGNs connect their education
to real-life situations. Specific information about standards This work is supported by Hibah PITTA 2018 funded by
of accreditation and hospital nursing policies help NGNs Directorate of Research and Community Services Universitas
to better assimilate into the hospital culture. Education Indonesia No. 5578/UN2.R3.1/HKP.05.00/2018.
about safety, quality improvement, patient-centered care,
communication, and teamwork, all included in the standard References
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