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This study investigated the influence of personal factors, orientation, continuing education, and staffing shortage on the satisfaction, intent to leave their job, and intent to leave the profession of a random sample of new graduate nurses. The findings indicate that orientation programs are essential to the retention and satisfaction. Given current economic constraints, this study supports nurse executives' ability to advocate for and receive funding for transition-to-work programs.
This study investigated the influence of personal factors, orientation, continuing education, and staffing shortage on the satisfaction, intent to leave their job, and intent to leave the profession of a random sample of new graduate nurses. The findings indicate that orientation programs are essential to the retention and satisfaction. Given current economic constraints, this study supports nurse executives' ability to advocate for and receive funding for transition-to-work programs.
This study investigated the influence of personal factors, orientation, continuing education, and staffing shortage on the satisfaction, intent to leave their job, and intent to leave the profession of a random sample of new graduate nurses. The findings indicate that orientation programs are essential to the retention and satisfaction. Given current economic constraints, this study supports nurse executives' ability to advocate for and receive funding for transition-to-work programs.
New graduate nurse transitioning: Necessary or nice?
Elaine S. Scott, RN, PhD
4 , Martha Keehner Engelke, RN, PhD, Melvin Swanson, BS, PhD East Carolina University School of Nursing, Greenville, NC 27858, USA Received 1 March 2006; revised 19 December 2006; accepted 19 December 2006 Abstract This study investigated the influence of personal factors, orientation, continuing education, and staffing shortage on the satisfaction, intent to leave their job, and intent to leave the profession of a random sample of new graduate nurses from varied facilities and geographic locations. It further examined the influence of personal factors and orientation on turnover rates among new graduate nurses. The findings indicate that orientation programs are essential to the retention and satisfaction of new graduate nurses. Given current economic constraints, this study supports nurse executives ability to advocate for and receive funding for transition-to-work programs as well as the placement of new graduate nurses in well-staffed units. D 2008 Elsevier Inc. All rights reserved. 1. Introduction New graduate nurses recruitment into and retention in the workplace are fundamental strategies for ensuring that health care systems have the continued capacity to deliver patient care (Berliner & Ginzberg, 2002). New graduate nurses come into the profession through varied educational avenues and demonstrate a wide range of competence and confidence levels in their new roles. In addition, todays new graduates enter a chaotic workplace characterized by nursing shortages, high patient acuity, and scarce resources. Nurse executives are challenged to transition these new graduate nurses in a way that will develop proficiency, foster satisfaction, and encourage retention. Although nurse executives know experientially that the first year of practice influences nurses retention and professional satisfaction, economic constraints and minimal research validation often limit their ability to develop and fund extended nursing internships and orientations. Con- temporary concerns for high rates of new graduate turnover and poor beginning technical competencies have spurred initiatives to develop standardized nursing resi- dency programs (Johnson & Cleary, 2006). In addition, studies that have linked patient safety and outcomes to the quality and quantity of nursing care have resulted in a litany of new graduate transition recommendations, includ- ing those from notable sources such as the Institute of Medicine (2004), the American Hospital Association Commission on Workforce for Hospitals and Health Systems (2002), the American Nurses Association [ANA] (2002), and the American Association of Colleges of Nursing (2002). The purpose of this study was to investigate the influence of anticipatory and organizational socialization variables on the job and career satisfaction, intent to leave their current position, turnover, and intent to leave the nursing profession of a random sample of new graduate nurses from varied facilities and geographic locations. The results of this research are of interest to nurse educators and executives. This study increases understanding of the influence that various personal and organizational conditions have on new graduate nurses. Its findings also support nurse executives ability to advocate for funding to support transition-to-work programs and validate current national and state initiatives to determine optimal transition programs. 2. Background The first year in a profession establishes an individuals career framework and influences long-term professional development and satisfaction. In nursing, the first few years of employment are ideally a critical learning period during which new graduate nurses enter as novices and receive ongoing education, experience, and support to socialize 0897-1897/$ see front matter D 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.apnr.2006.12.002 4 Corresponding author. Tel.: +1 252 744 6383 (work), +1 910 328 2851 (home); fax: +1 252 744 6392. E-mail address: scottel@ecu.edu (E.S. Scott). Available online at www.sciencedirect.com Applied Nursing Research 21 (2008) 7583 www.elsevier.com/locate/apnr them into the role of a competent and satisfied professional nurse (Benner, 1984). Orientation programs, internships, and preceptor relationships all contribute to the develop- ment of proficiency and self-assurance among new graduate nurses. The business literature offers well-substantiated theoret- ical frameworks for analyzing the transition of students from the academic world to the world of work. Socialization into work is described by most organizational theorists as a multistage process of prework experience, actual work encounter, and adjustment (Jablin, 1987; Van Maanen & Schein, 1979). Hinshaw, Smeltzer, and Atwood (1987) were the first researchers to apply these theories to nursing, and they discovered that various individual and organizational factors influence anticipated turnover and satisfaction. Using a comprehensive review of relevant business and nursing literature, we designed a conceptual model to illustrate possible influences on the successful transition of new graduate nurses into the workplace (Fig. 1). 3. Description of the conceptual framework 3.1. Anticipatory socialization: what happens before work The period of anticipatory socialization contributes significantly to the expectations that new graduates bring into their first job. New graduate nurses enter the profession through a variety of educational processes and are diverse in age, marital status, race, and sex. These differences in personal and educational experiences affect the images that students develop about what the world of work will be like after graduation. 3.2. Organizational socialization: what happens when work begins New graduate nurses enter the workplace with unique personal attributes and encounter varied socialization methods and organizational cultures. Currently, almost all health care systems use orientation programs to transition new graduates; however, programs vary in intensity and dimension, ranging from brief informal programs to extended formal programs that include preceptors and mentors during an internship or residency program. Limited research studies on the effectiveness and outcomes of orientation exist (Wanous & Reichers, 2000). Because of the different transition standards in nursing, operational definitions of orientation also vary. Despite a positive association between orientation and reduced work anxiety, more realistic job expectations, and increased organizational commitment, many organizations have decreased orienta- tion periods in response to economic pressures (Ellerton & Gregor, 2003). Another dimension of organizational socialization is the work environment. New graduate nurses feel heightened work stress for a period of up to 1 year (Casey, Fink, Krugman, & Propst, 2004). Stressors include feeling unable to set priorities and delegate as well as perform procedures, poor work environments, nursing supervisors, and physician Fig. 1. Conceptual model of the transition of new graduate nurses into the workplace. E.S. Scott et al. / Applied Nursing Research 21 (2008) 7583 76 relations (Casey et al., 2004; Heslop, McIntyre, & Ives, 2001). For nurses, poor working conditions are a primary cause of work stress and job dissatisfaction (Buerhaus, Staiger, & Auerbach, 2000; Shader et al., 2001; Steinbrook, 2002; Stordeur et al., 2001; Boychuk-Duchscher, 2001). In a comprehensive review of nurses work stress, the most often cited causes were workload, inadequate staffing, and time pressures (McVicar, 2003). New graduate nurses are a part of their respective intense workplaces, yet the influence of specific work stressors on new graduate nurses has had limited exploration (Chang & Hancock, 2003; Halfer & Graf, 2006). 3.3. Socialization: outcomes of synergy and dissonance Anticipatory socialization factors influence new graduate nurses understanding of and preparation for the real world of work. Positive work environments and effective organi- zational transition as well as socialization strategies provide an initial affirmative experience of the organization; an introduction to coworkers and managers; an understanding of the organizational policy, process, and culture; and a solid framework of competencies for the job. If new graduate nurses master the realities of practice, they would develop a sense of work satisfaction and career satisfaction. However, if there is a high level of dissonance between nurses expectations and workplace realities, nurses would be more likely to experience a traumatic transition into the nursing profession (Kramer, 1974). Research studies on the association between satisfac- tion and the anticipatory socialization variables of age, marital status, race, and educational preparation are limited and conflicting in their findings. In their early work, Hinshaw et al. (1987) found an association between the amount of education in nursing and actual turnover. Blegen, Vaughn, and Goode (2001) found low correla- tions between age, educational preparation, and satisfac- tion, whereas Adams and Bond (2000) found no association between these variables. Yamashita (1995) found increased satisfaction among nurses who were married or older. Marital status was also found to be related to satisfaction by Yaktin, Azoury, and Doumit (2003) as well as Cimete, Gencalp, and Keskin (2003), with the married nurses in their studies being more satisfied. Winter-Collins and MacDaniel (2000) found no differ- ence between the satisfaction levels of new ADN (Associate Degree in Nursing) graduates and those of new BSN (Bachelor of Science in Nursing) graduates. However, Rambur, Palumbo, McIntosh, and Mongeon (2003) found that nurses educational preparation was associated with their intent to leave their job and that BSN nurses were more satisfied and less likely to leave. With the exception of preceptorships, the influence of organizational transition methods on new graduates career satisfaction and job satisfaction, intent to leave, and turnover has primarily been descriptive in nature (Casey et al., 2004). Research studies on new graduate nurses orientation are most often limited to anecdotal accounts of successes based on one hospitals experiences. No study has examined the association between attendance at specific continuing education (CE) programs and socialization outcomes; however, the literature frequently cites lack of experience with delegation as a cause of frustration and worry among new graduate nurses (Ross & Clifford, 2002). Early (e.g., Hinshaw et al, 1987) and contemporary (e.g., McVicar, 2003) work have linked inadequate staffing and time pressures to nurses work stress and job dissatisfaction. Limiting new graduate stressors and fostering positive work environments are essential satisfaction strategies; however, the influence of transitional methods and environmental factors on new graduate nurses remains relatively unex- plored (Bowles & Candela, 2005). 4. Methods This study was a secondary analysis of data collected by the North Carolina Center for Nursing (NCCN). The sample was drawn from among nurses who were actively employed and newly licensed by the North Carolina Board of Nursing for a period not shorter than 6 months and not longer than 2 years. The participants were identified through random stratified sampling of new graduate nurses included in the North Carolina Board of Nursing database. Permission was obtained to deidentify and use the sample of 329 nurses for analysis. Before implementing the study, we obtained approval from the East Carolina University Institutional Review Board. The NCCN researchers developed a survey instrument to gather information about new graduate nurses. This tool was reviewed by a panel of experts to establish its content validity and included questions successfully used in previous nursing studies by the center. Embedded in the survey tool were seven questions measuring job satisfaction and career satisfaction. The internal consistency and reliability of these satisfaction items were confirmed in a previous study on general staff nurses (Shaver & Lacey, 2003). Although many anticipatory and organizational sociali- zation factors have been found to influence satisfaction, intent to leave, and turnover (Fig. 1), only 12 variables collected from the NCCN survey were coded and used in this study; these items were age (in actual years), race (White or non-White), marital status (married/widowed or single/divorced), education (ADN/Diploma or BSN), the quantity of orientation (number of weeks), the quality of orientation (met needs or did not meet needs), the frequency of staffing shortages (daily or weekly or more frequently), level of job satisfaction (satisfied or dissatisfied), level of career satisfaction (satisfied or dissatisfied), intent to leave current position ( z3 or b3 years), intent to leave nursing ( z3 or b3 years), and turnover (one position and employer or more than one position and employer). Descriptive data collected by the NCCN were used to characterize the E.S. Scott et al. / Applied Nursing Research 21 (2008) 7583 77 sample. These data included each new graduate nurses current employment status, position type, work setting, number of positions and employers, hours worked per week, and average patient caseload per day. The turnover history of the participants was self- reported at the same time other data were collected for the survey. This limited the analysis of independent variables that might influence turnover, allowing only those that preceded turnover (age, race, marital status, and educational preparation) to be used as anticipatory socialization items and only quantity and quality of orientation, which specifically referred to the participants first job position, to be used as organizational socialization factors. For other items related to organizational socialization, it was impos- sible to determine if respondents who had turned over were referring to their current or previous job; therefore, the lack of clarity in temporal sequence precluded analysis of these influences on turnover. Simple descriptive analysis provided an overview of the sample, including the presence of missing data and outliers. Using v 2 analysis, we examined the associations between categorical independent variables and the outcome variables of nurses turnover, job satisfaction, career satisfaction, intent to leave their current position, and intent to leave the nursing profession. A p value of .05 or lower was used to determine statistical significance in all analyses. Those items that did not evidence significance with the use of v 2 analysis were excluded from the binary logistic regression analyses used to examine the relationship of independent variables to the outcome variables of nurses job satisfac- tion, career satisfaction, and intent to leave their current position. Table 1 shows the univariate analysis results for the predictor variables that were statistically significant. A test of the full model for job satisfaction using the five Table 1 Univariate analysis of predictor variables related to the participants job satisfaction, career satisfaction, and intent to leave their current position in less than 3 years ( p b .025) Variable Satisfied [n (%)] Not satisfied [n (%)] Statistics v 2 p Job satisfaction Marital status Single/Divorced/ Separated 92 (51.7) 86 (48.3) 5.848 .016 Married/Widowed 98 (64.9) 53 (35.1) Race White 135 (47.9) 147 (52.1) 5.197 .023 Non-White 10 (27.8) 27 (72.2) Quality of orientation Completely met needs 70 (58.8) 49 (41.2) 15.137 b.001 Somewhat/ Not at all 70 (36.3) 123 (63.7) Frequency of short staffing Daily 16 (20.3) 63 (79.7) 27.219 b.001 Weekly or more frequently 133 (53.8) 114 (46.2) Career satisfaction Satisfied 128 (54.9) 105 (45.1) 27.459 b.001 Not satisfied 22 (23.2) 73 (76.8) Career satisfaction Marital status Single/Divorced/ Separated 87 (62.6) 52 (37.4) 8.365 .004 Married/Widowed 146 (77.2) 43 (22.8) Age b25 years 78 (66.1) 40 (33.9) 2.182 .140 z25 years 155 (73.8) 55 (26.2) Degree ADN/Diploma 124 (80.5) 30 (19.5) 12.970 b.001 BSN 102 (62.2) 62 (37.8) Quality of orientation Completely met needs 95 (79.8) 24 (20.2) 6.736 .009 Somewhat/ Not at all 127 (66.1) 65 (33.9) Frequency of short staffing Daily 45 (57.0) 34 (43.0) 10.115 .001 Weekly or more frequently 186 (75.6) 60 (24.4) Job satisfaction Satisfied 128 (85.3) 22 (14.7) 27.459 b.001 Not satisfied 105 (59.0) 73 (41.0) Variable Intent to leave current position Statistics b3 years [n (%)] z3 years [n (%)] v 2 p Marital status Single/Divorced/ Separated 76 (55.1) 62 (44.9) 10.757 .001 Married/Widowed 70 (36.8) 120 (63.2) Race White 120 (42.7) 161 (57.3) 5.784 .016 Non-White 23 (63.9) 13 (36.1) Quality of orientation Completely met needs 41 (34.7) 77 (65.3) 6.237 .013 Somewhat/ Not at all 95 (49.2) 98 (50.8) Table 1 (continued) Variable Intent to leave current position Statistics b3 years [n (%)] z3 years [n (%)] v 2 p CE on delegation Yes 108 (41.2) 154 (58.8) 5.709 .017 No 38 (57.6) 28 (42.4) CE on conflict management Yes 110 (42.8) 147 (57.2) 1.407 .236 No 36 (50.7) 35 (49.3) Frequency of short staffing Daily 49 (62.0) 30 (38.0) 12.803 b.001 Weekly or more frequently 96 (39.0) 150 (61.0) Job satisfaction Satisfied 40 (26.7) 110 (73.3) 35.639 b.001 Not satisfied 106 (59.6) 72 (40.4) Career satisfaction Satisfied 81 (34.8) 152 (65.2) 32.043 b.001 Not satisfied 65 (69.1) 29 (30.9) E.S. Scott et al. / Applied Nursing Research 21 (2008) 7583 78 determined predictors against a constant-only model was statistically reliable, v 2 (5, n = 285) = 69.15, p b .001. This was also true for the predictors of career satisfaction, v 2 (6, n = 298) = 56.39, p b .001, suggesting that the predictors, as a set, reliably distinguished between new graduate nurses who were satisfied with their job and career and those who were not. The levels of variance in satisfaction accounted for by the model were 27.8% for job satisfaction and 24.7% for career satisfaction. Partic- ipants who were satisfied with their job were predicted 64.1% of the time, whereas those who were dissatisfied with their job were predicted 75.3% of the time, resulting in an overall success rate of 70%. The model successfully predicted 91.1% of participants who were satisfied with their career but only 37.6% of those who were dissatisfied, resulting in an overall prediction rate of 75.8%. In the analysis of the participants intent to leave their current job, job satisfaction and career satisfaction were added as independent variables based on the original work of Hinshaw (1987), which suggested that they were separate elements associated with anticipated turnover. A test of the full model with eight predictors against a constant-only model was statistically reliable, v 2 (8, n = 296) = 58.99, p b .001, indicating that the predictors, as a set, reliably distinguished between new nurses who said they would leave their current job in less than 3 years and those who said they would not. The level of variance in intent to leave accounted for by the model was 24.2%. Participants intending to stay longer than 3 years were successfully predicted 78% of the time, whereas those intending to leave within 3 years were successfully predicted 59.8% of the time, resulting in an overall prediction success rate of 70%. Table 2 shows regression coefficients, Wald statistics, p values, odds ratios, and 95% confidence intervals for the predictors of job satisfaction and career satisfaction as well as nurses intent to leave their current job. The Hosmer Lemeshow goodness-of-fit v 2 analysis outcomes for job satisfaction ( p = .793) and nurses intent to leave their job ( p = .59) were not significant, showing good fit between observed and predicted values. The v 2 analysis outcome for career satisfaction was significant ( p = .05), indicating poor fit between observed and predicted values. This poor fit was probably caused by the small number of participants reporting career dissatisfaction. The analysis of intent to leave the nursing profession was limited because only 6% of the sample intended to leave within 3 years. This precluded a multivariate analysis with logistic regression; however, univariate analysis of the associations of job satisfaction, career satisfaction, and nurses intent to leave their current position in less than 3 years with the intent to leave nursing in less than 3 years found that only career satisfaction ( p V .001) and nurses intent to leave their current job ( p V .001) were significantly associated with intent to leave nursing in less than 3 years. 5. Results The study sample was predominantly White and female; the mean age of the participants was 29 years. Educational preparation was equally divided between BSN and ADN/ Diploma; most of the participants had received an orienta- tion to their first job (94.8%) and had attended CE programs (81.5%). The hospital was the predominant work setting Table 2 Logistic regression analysis of variables predicting participants job satisfaction, career satisfaction, and intent to leave their current position et al. in less than 3 years Variable B Wald statistic p Odds ratio (95% confidence interval) Job satisfaction Quality of orientation 0.883 10.469 .001 2.419 (1.4174.130) Marital status 0.534 3.889 .049 1.716 (1.0032.900) Frequency of short staffing 1.755 22.280 b.001 5.784 (2.79111.986) Race 0.736 2.654 .103 2.088 (0.8615.062) Career satisfaction 1.206 13.926 b.001 3.339 (1.7736.290) Career satisfaction Quality of orientation 0.393 1.597 .206 1.482 (0.8052.728) Marital status 0.437 2.322 .128 1.548 (0.8822.716) Age 0.011 0.001 .971 0.989 (0.5491.784) Frequency of short staffing 0.619 3.781 .052 1.857 (0.9953.464) Educational preparation 1.117 13.383 b.001 3.055 (1.6795.556) Job satisfaction 1.432 18.714 b.001 4.188 (2.1898.013) Intent to leave current position in b3 years Quality of orientation 0.224 0.649 .420 1.251 (0.7252.157) Marital status 0.540 2.871 .090 1.574 (0.9312.659) Frequency of short staffing 0.550 2.926 .087 1.733 (0.9233.254) CE on delegation 0.771 4.875 .027 2.162 (1.0904.285) CE on conflict management 0.045 0.016 .899 0.956 (0.4801.906) Race 0.787 3.442 .064 2.197 (0.9575.048) Job satisfaction 0.785 7.632 .006 2.192 (1.2563.825) Career satisfaction 1.097 13.359 b.001 2.996 (1.6635.395) E.S. Scott et al. / Applied Nursing Research 21 (2008) 7583 79 (81.1%), with most of the participants holding staff or general duty positions (71.1%). Among the new graduate nurses surveyed, 54.1% were dissatisfied with their current job and 55.0% had already left their first job but 70.8% were satisfied with the career of nursing. In this study, 58.7% of the respondents felt that the orientation they received had not completely met their needs. New graduate nurses reported extreme differences in the amount of orientation received, ranging from as little as half a week to as much as 1 year. Most of the new nurses reported staffing shortages as a work reality, with 24% stating they experienced daily staffing shortages within their work units. Additional demographic and statistical data are shown in Table 3. Only the predictor variables of quantity and quality of orientation were significantly associated with new graduate nurses turnover. The orientation length for new graduate nurses who turned over in their first nursing job (M = 7.8, SD = 6.35) averaged almost 2 weeks less as compared with the orientation length for those who did not turn over (M = 9.7, SD = 6.39), t(313) = 2.65, p = .008. The turnover rate for those who felt that their orientation completely met their needs was 45%, whereas the turnover rate for those who noted that their orientation had not completely met their needs was 60%, v 2 (1) = 6.44, p = .01. New graduate nurses who evidenced satisfaction with their job were 2.4 times more likely to also report being completely satisfied with their orientation. In addition, these nurses were 3.3 times more likely to be satisfied with nursing as a career. New graduates who were satisfied with their job were also 1.7 times more likely to be married or widowed and 5.2 times more likely to be White. The strongest predictor of job satisfaction was Table 3 Descriptive statistics of study variables Characteristic Frequency (valid %) Range M (SD) Frequency of short staffing Not more than weekly 247 (75.1) Daily 79 (24.0) Missing 3 (0.9) Type of setting Hospital 267 (81.1) Nursing home/ Rehabilitation facility 10 (3.0) Community 52 (15.9) Missing 0 Orientation in first position Yes 310 (94.2) No 12 (3.7) Missing 7 (2.1) No. of weeks of orientation 0.652 8.6 (6.43) Orientation met needs Completely 119 (36.2) Somewhat/Not at all 193 (58.7) Missing 17 (5.1) Job satisfaction Satisfied 151 (45.9) Not satisfied 178 (54.1) Missing 0 Career satisfaction Satisfied 233 (70.8) Not satisfied 95 (28.9) Missing 1 (0.3) Intent to leave current position b3 years 146 (44.5) z3 years 182 (55.5) Missing 1 Intent to leave nursing b3 years 20 (6.1) z3 years 308 (93.9) Missing 1 Turnover Turnover 181 (55.0) No turnover 148 (45.0) Missing 0 Age b25 years 118 (35.8) 2530 years 117 (35.6) 2149 29.1 (6.66) N30 years 94 (28.6) Missing 0 Race White 282 (86.5) Non-White 37 (13.5) Missing 0 Marital status Single/Divorced 139 (42.2) Married/Widowed 190 (57.8) Missing 0 Sex Female 307 (93.3) Male 17 (5.2) Missing 5 (1.5) Educational preparation Diploma/ADN 164 (49.8) BSN 165 (50.2) Missing 0 Table 3 (continued) Characteristic Frequency (valid %) Range M (SD) Age (years) by educational preparation Diploma/ADN 164 (49.8) 2148 30.9 (7.04) BSN 165 (50.2) 2249 27.5 (5.88) Missing 0 No. of employers 1 267 (81.2) z2 59 (17.9) 08 1.6 (0.969) Missing 3 (0.9) No. of positions 1 143 (43.5) 18 1.8 (1.01) z2 172 (52.3) Missing 14 (4.2) Type of position Staff/General Duty Nurse 234 (71.2) Home/Office/School Nurse 31 (9.4) Case Manager/Utilization Review Nurse/Clinical Nurse Specialist 7 (2.1) Team Leader/Unit Manager 51 (15.5) Other 4 (1.2) Missing 2 (0.6) E.S. Scott et al. / Applied Nursing Research 21 (2008) 7583 80 frequency of staffing shortage. New graduate nurses satisfied with their job were 5.8 times more likely than other graduate nurses to report staffing shortages that occurred weekly or not at all rather than daily. New graduate nurses experiencing daily staffing shortages were also more dissatisfied with nursing as a career, with the relationship between staffing shortage and dissatisfaction approaching significance ( p = .052). The best predictors of career satisfaction were educa- tional preparation and job satisfaction. The ADN nurses were 3.1 times more likely than the BSN nurses to be satisfied with nursing as a career. New graduate nurses who reported a high degree of satisfaction with their current job were 4.2 times more likely to also report a high degree of satisfaction with the career of nursing. The participants intent to leave their current position was predicted by job satisfaction and career satisfaction and by attendance at a CE program on delegation. New graduate nurses who intended to leave their current position within 3 years were 2.2 times as likely as others to be dissatisfied with their job and 2.9 times as likely to be dissatisfied with the career of nursing. New graduate nurses who had attended a CE program on delegation were 2.2 times as likely as peers to leave their job within 3 years. Intent to leave the nursing profession in less than 3 years was reported by 20 new graduate nurses and was only associated with career satisfaction. Nurses who did not like being a nurse were more likely to report a desire to leave the profession. 6. Summary and conclusions One of the most significant findings of this study is the critical role that orientation in the first job plays in promoting new graduate nurses job satisfaction and retention. Although the duration and quality of orientation reduced turnover of new graduates, regardless of whether the new nurses remained in their first position or changed jobs, those who experienced a longer orientation that met all of their needs were more satisfied with their current job. This suggests that the first nursing orientation experience might have an influence on job satisfaction over the initial 1- to 2-year period of transition from school to work. The study on competence development by Benner (1984) indicated that nurses need 2 to 3 years to become competent practitioners, and new graduate nurses often cite the development of confidence and competence as essential for feeling good about their job. Future research efforts should evaluate if the development of confidence and competence as well as job satisfaction in new graduates who remain in their first job for at least 1 year are greater than those in new graduates who change units or organ- izations. Part of competence development involves attend- ing relevant CE programs. Many new nurses struggle with the ability to delegate, and this research showed an association between nurses attendance at an educational program on delegation and their intent to leave their job. This might indicate that these nurses were struggling with this issue. Nursings Agenda for the Future (ANA, 2002) promoted innovation in recruitment and retention as a primary focus for nurse leaders. Within this domain, a specific recom- mendation was made to badvocate for standardized intern- ships and residencies through partnerships between schools of nursing, professional organizations and practice sitesQ (ANA, 2002, p. 17). This study supports how essential it is to standardize and implement transition-to-work programs. The current initiatives to develop and research these programs already hold promise, with increased retention and competence development being preliminarily affirmed in American projects (Krsek, 2006). While the evidence from these large demonstration projects are gathered and orientation programs are developed, the strong association found in this study between orientation, job satisfaction, and turnover supports the need for health care systems to recognize the value of orientation for new graduates. Despite budget constraints and reimbursement reductions, nurse executives need to advocate for orientation as a budget priority. Nurse executives also need to examine new graduate nurses perceptions of the quality and duration of orientation experiences, gather feedback about these per- ceptions usefulness during nurses first year of practice, and correlate these findings with job satisfaction, career satisfaction, and turnover. Another noteworthy study finding is the association between staffing shortage and job as well as career dissatisfaction in new graduates. Nurse leaders often recruit new graduates to work in understaffed units rather than placing experienced nurses in these areas to stabilize and alter the culture. Experienced nurses are more competent in handling multiple priorities and larger caseloads, yet often new graduate nurses have to begin practice in these at-risk environments. Health care organizations and nurse leaders need to buffer the work stress experienced by new graduate nurses by placing them in units with adequate staffing and expert nurse mentors. In this study, the new graduate nurses career satisfaction and job satisfaction were also strong predictors of their intent to leave their current job and to leave nursing within 3 years. Previous research studies have linked intent to leave a job with turnover, suggesting that placing new graduate nurses in poorly staffed units might result in increased turnover. The finding that ADN nurses had higher degrees of career satisfaction could indicate a difference in the expectation and fulfillment needs of baccalaureate nurses. Current recommendations call for an increase in the ratio of BSN to ADN nurses to ensure patient safety and quality outcomes (NCCN, 2002). However, although a higher percentage of BSN graduates in a unit might lead to improved patient safety, this study suggests that BSN graduates may be less tolerant of adverse work conditions and more likely to seek employment in other fields as E.S. Scott et al. / Applied Nursing Research 21 (2008) 7583 81 compared with ADN graduates. This study supports monitoring the factors that satisfy and those that dissatisfy new graduate nurses from orientation through the first 2 years of their practice and evaluating differences based on educational preparation. These findings should be used to structure relevant incentives, educational support, and practice environments that meet the needs of BSN and ADN nurses. A higher level of career satisfaction among White nurses also raises concern that the needs of non- White nurses are not being met and should be further explored by nurse leaders and researchers. Nursing executives must continue to find funding for adequate orientation and transition-to-work programs for new graduate nurses. Leaders must also promote the placement of these new nurses in well-staffed units where they can gain competence and confidence rather than be overwhelmed by daily workloads. Current efforts to construct, standardize, and even mandate nursing residen- cies and internships within the profession should be promoted because there is a clear relationship between the quality as well as quantity of new graduate nurses orientation and the satisfaction as well as retention of these novice professionals. This research reiterates the importance of the work that the nursing profession is doing through transition-to-work demonstration projects and supports the interim needs of nursing executives who are battling with budgets to provide an adequate orientation for new graduate nurses. Acknowledgments We thank the NCCN, Dr. Brenda Cleary, and Linda Lacey for their assistance in obtaining the data used in this study. References Adams, A., & Bonds, S. (2000). Hospital nurses job satisfaction, individual and organizational characteristics. Journal of Advanced Nursing, 32(3), 536543. American Association of Colleges of Nursing (2002). 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The Educational Preparation of Undergraduate Nursing Students in Pharmacology Clinical Nurses' Perceptions and Experiences of Graduate Nurses' Medication Knowledge