Qualitative Research Report: Critical Appraisal for Qualitative Studies

Critical Appraisal for Qualitative Studies Directions for use of this tool: The questions below are prompts to guide you in critiquing a quantitative study. The questions should be answered with more than a yes or no. Instead you should expound on each discussion point. 1) Are the results of the study valid (i.e., trustworthy and credible)? a) How were study participants chosen? b) How were accuracy and completeness of data assured? c) How plausible/believable are the results? d) Are implications of the research stated? 2) What were the results? a) Does the research approach fit the purpose of the study? i) How does the researcher identify the study approach? (1) Are language and concepts consistent with the approach? (2) Are data collection and analysis techniques appropriate? ii) Is the significance/importance of the study explicit? (1) Does review of the literature support a need for the study? (2) What is the study’s potential contribution? iii) Is the sampling strategy clear and guided by study needs? (1) Does the researcher control selection of the sample? (2) Do sample composition and size reflect study needs? b) Is the phenomenon (human experience) clearly identified? i) Are data collection procedures clear? (1) Are sources and means of verifying data explicit? (2) Are researcher roles and activities explained? (3) Are data analysis procedures described? (4) Does analysis guide direction of sampling and when it ends? (5) Are data management processes described? c) What are the reported results (description or interpretation)? i) How are specific findings presented? (1) Is presentation logical, consistent, and easy to follow? (2) Do quotes fit the findings they are intended to illustrate? ii) How are overall results presented? (1) Are meanings derived from data described in context? (2) Does the writing effectively promote understanding? 3) Will the results help me in caring for my patients? a) Are the results relevant to persons in similar situations? b) Are the results relevant to patient values and/or circumstances? c) How may the results be applied in clinical practice? Adapted from: © Fineout-Overholt & Melnyk 2005. This form may be used for educational, practice change & research purposes without Permission. Qualitative Research Report: Critical Appraisal for Qualitative Studies

ORIGINAL RESEARCH Hearing the Voices of Newly Licensed RNs: The Transition to Practice A qualitative study suggests that new nurses need more guidance and support than they’re getting. D espite slow, continued growth in the U.S. economy in general and in the health care industry in particular, nursing shortages are predicted to persist over the next two decades. The turnover rate for bedside nurses was 11% in 2012, a rate that increased to 13% in a January 2013 survey.1 That same survey found that nearly half of U.S. hospitals reported RN vacancy rates of less than 5%; a third of hospitals reported vacancy rates ­between 5% and 9.9%, and 18% reported ­vacancy rates of 10% and higher.1 Buerhaus and colleagues projected in 2009 that although a higherthan-expected number of new nurses were entering the workforce, by 2025 the U.S. nursing shortage would reach 260,000 nurses.2 With the average age of RNs nearly 45 years, 10-to-15-year projections estimate that 1 million nurses over age 50 will reach retirement age.3 In an effort to improve nurse staffing, hospitals have actively recruited newly licensed RNs (NLRNs). Consequently, first-year turnover rates for new nurses remain relatively high, ranging from 17% to 22%.4, 5 High RN turnover rates and reduced RN staffing have been linked to increased rates of hospital-related mortality, hospital-acquired pneumonia, hospitalassociated falls and pressure ulcers, medication errors, hospital-acquired urinary tract infections, and readmissions.6-12 Jones reported that the costs in 2007 associated with RN turnover were an estimated $88,000 per new nurse and $82,000 per experienced nurse.13 In light of these costs and the nursing shortage, organizations must better understand the NLRN’s transition from student to professional in order to increase rates of retention. 24 AJN ▼ November 2013 ▼ Vol. 113, No. 11 Our interest in NLRNs began early in our careers. We realized, through our own experience as new nurses and as preceptors, that nursing orientation does not give NLRNs the skills they need to make the shift from student to professional. Three of us (LS, LP, DJ) developed an extensive orientation program for NLRNs. One of us (BB) focused her doctoral work on the retention of NLRNs and the impact that orientation had on nurse retention.14 Two of us (KM, PLH) implemented a residency program for NLRNs at an integrated health care organization; one (PLH) furthered her interest in the NLRN’s transition to practice as a faculty member of an academic institution, and the other (KM) focused on understanding experiences of the NLRN’s first year of practice.15 Finally, one of us (FM), who worked as a bedside nurse for over 30 years, had a long history of mentoring and precepting NLRNs. And recently, three of us (LS, PLH, FM) conducted a study investigating the experience of the older bedside nurse and the transition to retirement,16 which sparked our interest in the NLRN’s transition to practice and the role older nurses play in that transition. LITERATURE REVIEW The first few months of employment is a crucial time in a nurse’s career.17 According to Benner’s novice-to-expert model, RNs enter the profession at the novice or advanced-beginner level18 and thus are at an early stage of applying clinical skill and reasoning. Hospital orientation programs help to ease the shift from novice to advanced beginner. But these programs vary in content and intensity, length and structure, and in their use of preceptors and ajnonline.com By LeeAnna Spiva, PhD, RN, Patricia L. Hart, PhD, RN, Lisa Pruner, MSN, RN, Donna Johnson, BSN, RN, Kenzie Martin, MSN, RN, Betsy Brakovich, DNP, MPA, RN, Frank McVay, BSN, RN, and Sency G. Mendoza, BSN, RN ABSTRACT Objective: The future of nursing depends on newly licensed RNs (NLRNs), who often need help in transitioning from an academic to a clinical setting. This study sought to describe the NLRN’s orientation experience and to identify ways of enhancing it. Qualitative Research Report: Critical Appraisal for Qualitative Studies

Methods: Using qualitative methods, a convenience sample of NLRNs was recruited and 21 were interviewed; audio recordings of the interviews were transcribed and validated for accuracy. Interpretative analysis of the transcripts sought to identify major patterns and themes. Results: Four patterns and 10 themes emerged from the data analysis: preceptor variability (with themes of satisfactory and unsatisfactory preceptorship), professional growth and confidence changing with time (with themes of learning through experience, learning to manage time, and learning to communicate), a sense of being nurtured (with themes of support through the program, the preceptor, and peers), and enhancing the transition (with themes of orientation enhancements and human resource enhancements). Conclusions: These qualitative findings provide insight into the NLRN’s transition from student to professional and suggest ways institutions might enhance orientation. Further study is warranted. Keywords: newly licensed RNs, qualitative research, turnover mentors during an internship or residency program.17 Scott and colleagues found that NLRNs who had a long orientation were more satisfied with their current job.17 We conducted a literature search using PubMed, Ovid, and EBSCOhost databases for studies conducted from 2004 to 2013. Search terms included new graduate nurse, acute care hospital, transition, turnover, retention, qualitative, orientation, and preceptor. The search strategy identified and retained published studies written in English. Our literature review revealed several well-­ recognized challenges NLRNs face in the transition to practice, including job stress, lack of knowledge and confidence, heavy workloads, too little support, inadequate skills in time management and critical thinking, and interprofessional conflict.14, 19-25 Casey and colleagues reported in 2004 that a majority of NLRNs entering the workforce did not possess the confidence and competence to assume accountability for patient safety.20 And the gap between theory and practice persists: in 2008, Burns and Poster identified a gap between the knowledge and skills students acquire and those needed in clinical settings,26 and a 2010 report by Benner and colleagues explains that many nursing students enter the profession unprepared to act as practitioners.27 But a preceptor can provide NLRNs the link between academics and clinical practice.28 Preceptor programs can increase NLRNs’ job satisfaction, augment their acquisition of skill and knowledge, enhance their confidence, smooth role transition and socialization, and increase retention rates.20, 29-35 Additionally, nurse residency programs have been an effective strategy ajn@wolterskluwer.com deployed by health care organizations to assist with NLRN transition to practice. Positive outcomes from these programs include improved self-confidence, satisfaction, and retention.24, 36 METHODS We sought to describe the orientation experience of NLRNs at one hospital in the southeastern United States. For this study, we defined the term NLRN as an RN licensed for no more than 12 months. We used grounded theory methodology as described by Glaser and Strauss to explore the experience of NLRNs.37 The research questions guiding us were: • What is the orientation experience of NLRNs who have completed the hospital’s orientation program? • What would enhance the NLRNs’ orientation experience? The acute care hospital where we conducted this study provides an extensive orientation program for NLRNs. It consists of a nurse residency program, an onsite “pipeline development team,” and a preceptorship. The year-long nurse residency program was developed by the University HealthSystem Consortium; NLRNs are placed into cohorts based on hire date and attend monthly educational sessions on the transition to professional nursing. The onsite pipeline development team consists of a nurse manager and a clinical nurse specialist who monitor the NLRNs’ orientation. The NLRNs report ­directly to the team during the orientation period. (Table 1 outlines the responsibilities of that team.) The preceptorship involves assigning an NLRN to an experienced RN during the unit orientation. AJN ▼ Qualitative Research Report: Critical Appraisal for Qualitative Studies

November 2013 ▼ Vol. 113, No. 11 25 The preceptor provides clinical supervision and support. Sample. This study was conducted between October 2010 and February 2012. We chose a convenience sample of NLRNs who had completed the hospital’s orientation program and were willing to participate in an audiotaped interview. We had a potential recruitment pool of 63 NLRNs. Prior to data collection, we obtained approval from the organization’s nursing research committee and institutional review board. The chief nursing officer gave NLRNs a recruitment flyer during the last formal class of orientation at the hospital; if interested in participating in the study, the NLRNs contacted one of the researchers to schedule an interview. Ten NLRNs responded and were interviewed. A flyer was then e-mailed to the pool of NLRNs; 11 responded and were interviewed. Two NLRNs were excluded: one was fired by the hospital and the other provided no contact information. Data collection and analysis took place simultaneously. Interviews took place in person or by telephone between 7 am and 7 pm, Monday through Friday, during the nurse’s work shift, and lasted from 30 minutes to one hour. All interviews were audiotaped and transcribed. each code. The coded data were reread to ensure codes and definitions were similar. If differences existed, data were recoded or additional codes and definitions were created. Codes were clustered into categories and themes. Subsequent interviews further validated the emerging themes and continued until no new data emerged. Categories and themes were examined for common meanings to identify similar patterns. The researchers conducted member checks with the NLRNs to verify study findings. Additionally, those of us conducting the interviews kept a journal in which we described the interview settings and participants’ nonverbal communication. For example, if we noted a participant crying, we noted this information and at a later time referenced these notes when reviewing the transcripts. We did not conduct statistical or analytical analysis on any of our observations because of the small amount of data collected. We maintained an audit trail so that other researchers can follow our procedures for future studies.39 RESULTS The sample included 21 NLRNs, 20 women and one man, working in the 633-bed, acute care hospital (see Table 2). The sample’s demographics represented ‘I was scared of telling my preceptor anything. She wanted me to answer with “Yes, ma’am” and would say my questions were stupid.’ Three of us (LS, FM, SGM) conducted unstructured, one-to-one interviews. We asked two openended questions: “Tell me about your orientation experience,” and “Tell me about factors that would improve or enhance the orientation experience.” We continued the interviews until we determined that data saturation had occurred with 21 interviews. Tape-recorded interviews were transcribed verbatim, and we used the constant-comparative method to analyze transcripts.38, 39 Data were analyzed by hand using all research team members. A written summary that included keywords and phrases from each interview was prepared to explore relationships and common meanings within the nurses’ stories. Interpretations were discussed among the researchers. Each sentence of the transcripts was coded using the NLRN’s words. Microsoft Word 2010 was used to format, code, and sort the data from the interview text. A codebook was created to list the definition of 26 AJN ▼ November 2013 ▼ Vol. 113, No. 11 those of the hospital’s overall nursing population in terms of sex, age, race, nursing degree, and health care experience. Four patterns emerged from the analysis (a pattern is a common meaning that was identified in all 21 interviews). Ten themes emerged from the four patterns (a theme is a common relationship that brought meaning to each pattern). Preceptor variability, the first pattern that emerged, had two themes, showing that preceptors enhanced or hindered NLRNs’ progression. Satisfactory preceptorship. Many NLRNs described their preceptors as knowledgeable, experienced, helpful, personable, and informative. Other positive attributes included having the ability to teach, a desire to assist the NLRN, good communication skills, a nurturing attitude, and the ability to give feedback on job performance. As one NLRN expressed it: ajnonline.com Table 1. Pipeline Development Team Responsibilities •• Ensuring standardization of initial orientation requirements •• Scheduling classes and clinical rotations •• Coordinating first-day activities and luncheon •• Providing educational sessions on best practices for high-priority issues including skin integrity, iv principles, and patient safety •• Qualitative Research Report: Critical Appraisal for Qualitative Studies

Monitoring and follow-up for verifying NLRN progression during orientation •• Completing weekly NLRN competency-development form •• Conducting clinical rounds •• Holding individual training sessions for NLRNs needing assistance with electronic documentation, critical thinking, specialty training, and medication administration •• Developing action plans and monitoring of performance issues My preceptor is knowledgeable, experienced, patient . . . [an] excellent teacher, key to my success, and trusting. I could communicate with her and did not feel threatened. I was able to ask questions, and did not have to worry about making a mistake and being yelled at. Many NLRNs said that the preceptor was critical in building their confidence and preparing them to practice independently. Being corrected in a nonjudgmental way was appreciated, as one NLRN said: “My preceptor was the best part of it and she acted like a shield moving me through the orientation. She always presented corrective action in an educational way and an opportunity to learn.” Another NLRN said her preceptor helped her become more independent over time: If I made a mistake, I was able to learn from the mistake. I was not afraid to ask questions. She would let me make my own decisions and would double check things for me. . . . In the beginning I needed help, approval, supervision, but by the end I was on my own. Unsatisfactory preceptorship. Some NLRNs described their preceptors as inconsistent or too inexperienced. One nurse was “miserable,” she said: I had a preceptor who was very conflicting with my personality and it was her first time precepting. Every time I came to work it was chaotic and I had no idea what to do. She started asking questions and I started crying. I would have left [the hospital] if I had not left ajn@wolterskluwer.com that unit. Everything that could have went wrong, went wrong. Several nurses described being nervous about communicating with a preceptor. One NLRN said: I was scared of telling my preceptor anything. She wanted me to answer with “Yes, ma’am” and would say my questions were stupid. I felt like I had to get things always right and it made me nervous. She would tell me in front of patients and others that I was not doing something right. Other NLRNs said their preceptors corrected them in an inappropriate way. One described what happened after she learned how to remove a drainage tube from another nurse on the unit: Apparently, the nurse did it differently than my preceptor, and in front of the family, my preceptor said, “Oh you’re not going to do this,” and I responded, “This is how the nurse showed me.” While correction is necessary, she could have done it in a different way. Several NLRNs said they were expected to practice independently, with little supervision or guidance. As one NLRN said: My preceptor told me that I did not listen to her and was defensive. There was a meeting called and I had a rebuttal for almost all ­examples. I felt blasted that day and that it came out of nowhere. I do wish I had the AJN ▼ November 2013 ▼ Vol. 113, No. 11 27 Table 2. Demographics (N = 21) Characteristics n % Sex Male Female 1 4.5 20 95.5 15 71.4 Ethnicity/Race White African American 4 Other 2 19 9.6 Education Baccalaureate Associate’s degree 18 86 3 14 21 100 Employment status Full time Specialty area Adult medical–surgical 16 76.2 Adult step-down 3 14.3 Adult ICU 2 9.5 Health care–related position 9 42.9 Nursing assistant 4 19 Nurse extern 3 14.3 Nurse intern 1 4.8 None 4 Previous health care experience 19 Mean (SD) age in years, 29 (6.9) Mean (SD) months practiced, 5.43 (2.50) feedback because I did not know that they thought I was putting patients in danger. . . . For weeks, my preceptor was letting me practice independently and all of a sudden, I was doing everything wrong. She wanted a day or two to watch me because she had not been watching me enough before. I had to ask my preceptor to stay with me. Two days later, she said I could return to being independent. ­After the meeting, I did not understand why my preceptor let me be so independent. 28 AJN ▼ November 2013 ▼ Vol. 113, No. 11 Professional growth and confidence changed with time. This second pattern included three themes. Learning through experience. NLRNs recollected stories of immersing themselves in the learning process with the aim of attaining the knowledge, confidence, and skills to practice independently. In the beginning, several NLRNs said, they lacked th …