MINIMIZING INCIVILITY IN THE WORKPLACE TO INCREASE RETENTION OF NEW GRADUATE NURSES

by

AMANDA M. D’AMBRA

A thesis submitted in partial fulfillment of the requirements for the Honors in the Major Program in Nursing in the College of Nursing and in The Burnett Honors College at the University of Central Florida Orlando, Florida

Summer Term 2012

Thesis Chair:Diane R. Andrews

ABSTRACT

Efforts to maintain a sufficient nurse workforce are hampered by dissatisfaction with the work

environment.Incivility in the work environment is a major source of dissatisfaction. A healthy

work environment is associated with higher levels of job satisfaction and improved retention.

New graduate transition programs have been recommended as a deterrent to high levels of

turnover associated within the first two years of employment, some of which is related to

incivility. The purpose of this thesis was to examine the influence of incivility in the nursing

workplace on new graduate job satisfaction and determine if there is an association between

participation in new graduate nurse transition programs and satisfaction with the work

environment. A systematic review of the literature was performed using MEDLINE-

EBSCOhost, PsycInfo, and the Cumulative Index to Nursing and Allied Health Literature

(CINAHL) databases. Sixteen studies, which met search criteria, were reviewed. Themes that emerged included workplace incivility, nurse residency programs, mentoring through preceptors, and empowerment. Findings indicated that incivility in the workplace was a significant predictor of low job satisfaction in new graduate nurses. While graduate nurse transition programs are associated with improved satisfaction and retention rates for these nurses, nothing in the literature indicated that graduate nurse transition programs had a direct impact on empowerment and job satisfaction related to the incivility these nurses experience.

Keywords: New graduate nurse; incivility; work environment; transition programs; empowerment

ii DEDICATIONS

I would like to thank my wonderful husband, Mike D’Ambra, for always being my rock,

supporting me through my endeavors in life, and never giving up on me no matter how high or

low I may be.

I would like to thank my beautiful son, Drew D’Ambra, for always reminding me to laugh and

showing me that life is too short to worry about the small things.

I would like to thank my parents for teaching me that I can do anything I dream up. For instilling

in me the pride and ability to always strive for excellence in everything I do.

I would like to thank Heather Griffin and Jason Griffin for always being there to encourage me,

to support me, and to never let me slip.

Finally, I would like to thank every one of my fellow classmates for being there by my side

through this amazing adventure.

Without all of you, this would not be possible. Thank you for your love and support. I cannot

begin to express my love for all of you.

Amanda

iii ACKNOWLEDGEMENTS

I would like to thank the members of my committee: Dr. Diane Andrews, Dr. Donna Malvey,

Mr. Stephen Heglund, and Mrs. KrisannDraves. Thank you for all of your time, patience, and

amazing insight. Thank you for everything you do.

Thank you to all of the faculty and staff from the UCF College of Nursing for encouraging me to

go above and beyond.

A special thank you to Orlando Health for your generosity and financial support in awarding me

the Orlando Health Honors in the Major scholarship.

Thank you to the University of Central Florida for the wonderful resources you offer. Thank you

to all of the staff who make it possible for research to happen.

Finally, thank you to the Burnett Honors College for allowing me the opportunity to participate in the Honors in the Major program and awarding me the Honors in the Major scholarship. This

has been an amazing experience.

iv TABLE OF CONTENTS

Introduction ...... 1

Problem ...... 3

Purpose ...... 4

Background ...... 5

Incivility in the Workplace ...... 5

Nursing as an Oppressed Group ...... 6

Burnout ...... 7

Nurse Retention ...... 8

New Graduate Nurse Perception of the Work Environment ...... 10

Transition Programs ...... 11

Method ...... 14

Findings...... 16

Workplace Incivility ...... 18

New Graduate Nurse Transition Programs ...... 20

Residency Programs...... 20

Mentoringthrough preceptors...... 22

Empowerment ...... 23

Discussion ...... 25

Effect of Workplace Incivility on New Graduate Nurses ...... 25

Influence of New Graduate Nurse Transition Programs on Retention ...... 26

Residency Programs...... 26

v Mentoring through preceptors...... 27

The Importance of Healthy Work Environments...... 27

Limitations ...... 29

Nursing Implications ...... 30

Conclusions ...... 31

Appendix A: Figures ...... 32

Appendix B: Tables ...... 34

References ...... 52

vi

Introduction

Cyclic shortages of nurses have long hampered efforts to maintain a sufficient workforce.

One area of concern has been difficulty retaining professional, experienced nurses (Cherry &

Jacob, 2011). High rates of nurse turnover remain problematic for employers and impact the

quality of patient care (American Association of Colleges of Nursing, 2008; Bae, Mark,& Fried,

2010). While there are multiple influences upon turnover and expressed intent, incivility has been demonstrated to exert a significant influence (Laschinger, Leiter, Day, &Gilin, 2009).

Incivility in the workplace decreases job satisfaction and organizational commitment while increasing stated intent to leave.In a recent study, researchers interviewed 10 nurses to better understand why they were leaving the field of nursing. All of the participants cited that an unfriendly workplace was a major reason for leaving the profession (MacKusick&Minick, 2010).

Incivility in the nursing workplace has been the subject of multiple studies in an attempt to explain this phenomenon. Important factors such as burnout, horizontal violence, bullying, and verbal abuse have been identified.Burnout, in particular, occurs due to a prolonged response to chronic stressors on the job, which is triggered by overwhelming exhaustion, feelings of cynicism, and a sense of lack of accomplishment (Leiter&Maslach, 2009). This pattern of behavior has been found to impact both nurses and patients. Nurses who experience burnout have an increased intention of leaving their job within a year and they are more likely to make a patient error (Aiken, Clarke, Sloane, Sochalski, & Silber 2002). Exhaustion, one of the major

1 consequences of burnout, is strongly correlated to acts of cynicism toward other nurses

(Laschinger,Grau, Finegan, &Wilk 2010; Leiter&Maslach, 2009).

Cynicism is an act of horizontal violence. Horizontal violence is defined as non-physical

acts of hostility, such as, criticism, sabotage, and undermining (Duffy, 1995). It has been shown to be associated with low job satisfaction, increased rates of turnover, and diminished physical and psychological health (Vessey, Demarco, &DiFazio, 2010). Reports of horizontal violence in nursing work environments are persistent (Roberts, Demarco & Griffin, 2009). Oppression, in the form of overt and covert efforts to control the behavior of subordinates by those in positions of relative power, is often cited as the reason for this phenomenon (Farrell, 1997; Rowe &

Sherlock, 2005; Simons &Mawn, 2010; Stanley, Martin, Michel, Walton, & Nemeth, 2007).

Bullying, similar to horizontal violence, refers to a victim being subjected to repeated negative behavior, threats, and attacks (Quine, 2001). These threats can include belittling remarks, cynicism, verbal abuse, and humiliation from a co-worker (Quine, 2001; Rowe &

Sherlock, 2005). Bullying differs from horizontal violence in that a difference in power or status must be present in bullying (similar to oppression), while horizontal violence occurs among peers (Vessey, DeMarco, &DiFazio, 2010). This type of behavior has been found to have a profound effect on nursing retention as well as the health of the nurse. In one study, 76% of nurses considered leaving their job, 87% felt miserable and depressed, and 82% felt as though they did not want to return to work (Quine, 2001). Most studies on bullying have found an association between bullying and poor nurse retention with intention to leave the nursing field all together (Farrell 1997; McKenna, Smith, Poole, & Coverdale, 2003; Quine, 2001; Simons

&Mawn, 2010).

2 Problem

The conditions nurses experience in the work environment are associated with job satisfaction and nurse retention. Bullying, burnout, and horizontal violence have all been cited as major problems in nurse retention and job satisfaction among nurses (Laschinger et al., 2009;

MacKusick&Minick, 2010; McKenna et al., 2003; Quine, 2001; Simons &Mawn, 2010).

Bullying and horizontal violence, as examples of incivility in the workplace, are associated with

the experience of burnout. Job satisfaction and burnout are negatively correlated in that low job

satisfaction is closely associated with high levels of nurse burnout. In addition to the impact of incivility on burnout, burnout has also been associated with other conditions in the work environment. It is related to nurse-to-patient staffing ratios on medical/surgical units. An

increase of one extra patient per nurse was found to increase nurse burnout by 95% (Aiken et al.,

2002). Burnout has also been found to impact the quality of patient care. When the nurse-to-

patient ratio is increased from four to eight patients per nurse, it was found to be associated with

five additional deaths per 1000 patients (Aiken et al., 2002). New graduate nurses are especially

vulnerable to bullying, burnout and horizontal violence (Roberts et al., 2009). McKenna et al.

(2003) determined that nearly half of all new graduate nurses experienced incivility in the

workforce and Smith, Andrusyszyn and Laschinger(2010) reported that perceived co-worker

incivility was a significant factor in affective organizational commitment. Given the

vulnerability of new graduate nurses to incivility and the potential for a negative impact on

nurses, patients and employers, it is important to better understand this phenomenon.

Research suggests that as new nurses begin their socialization into the profession that

they are encouraged to accept incivility as a professional norm. MacIntosh (2006) reports that

3 nurse employees are fearful to report bullying. And those who do are told to remain quiet as

they most likely brought it upon themselves. In one study on abuse experienced by nursing students, 67% of those who experienced abuse did not report it due to lack of support and the perception that abuse is part of the nursing culture (Ferns &Meerabeau, 2009). In another study, nurses reported that they perceived administrators were accepting of this abusive type of behavior, and that in itself was more distressing than the actual harassment they were experiencing (MacKusick&Minick, 2010).

There is also a relationship between burnout and bullying which adversely impacts new

graduates. In a recent study bullying behaviors were determined to affect perception of burnout

in new graduate nurses (Laschinger et al., 2010). In another study of newly licensed nurses in the

United States, 184 nurses responded to a narrative survey question about their experience with

bullying in the workplace (Simons &Mawn, 2010). Among the 184 respondents, 139 nurses

reported being bullied, 17 of whom discussed specifically feeling bullied by imposition of longer

work hours due to their younger age, causing feelings of exhaustion along with burnout.

Purpose

The purpose of this thesis is to complete a literature review and synthesize previously

conducted research pertaining to bullying, horizontal violence, and burnout among new graduate

nurses. It is anticipated that the findings of this thesis will assist staff and management in the

identification of factors associated with incivility in the work environment and the effects of

incivility upon staff and patient care. It will also inform both staff and management of potential

interventions intended to reduce/eliminate incivility leading to better nurse retention.

4 Background

Nurse to nurse hostility has been known to exist within the profession, but extensive

study of the phenomenon is relatively new. There are many factors to consider in gaining

understanding of the incivility that exists amongst nurses. Incivility can develop alone or it can

be the result of other issues that exist within the nursing profession. In order to understand the

extent of the problem, the factors known to contribute to incivility and the impact of incivility

require study. These factors include nursing as an oppressed group, burnout, new graduate

nurse perception of the work environment, and nurse retention.

Incivility in the Workplace

Workplace incivility is defined as a low-intensity deviant behavior with intent to harm the target, in violation of workplace standards or consideration of respect for others (Laschinger et al., 2009). Although this behavior is of ‘low-intensity’ it is deemed to have dire emotional consequences on the victim. Research suggests that victimsof incivility show greater job stress, cognitive distraction, psychological distress, lower job satisfaction, and ultimately are more likely to leave the institution (Cortina &Magley, 2009). It is apparent that incivility amongst nurses can greatly impact nurse retention due to intention to leave the institution. Similarly, incivility can negatively affect safe patient care due to the effect of cognitive distraction and greater job stress.

To better understand the effects of nurse-to-nurse hostility, a scale has been developed called the Nursing Incivility Scale or (NIS). This scale was developed based on the

Multidimensional Incivility Scale that studied both internal and external incivility behaviors and

5 was adapted to fit more health care specific measures including nurse incivility (Guidroz,

Burnfield-Geimer, Clark, Schwetschenau, &Jex, 2010). This 43-item instrument includes subscales that represent three nursing incivility factors (free-riding, gossip/rumors, and inconsiderate behaviors) that participants are to rateon a five point Likert scale (Lewis

&Malecha, 2011). Results of the NIS can be used as a baseline to measure the level of incivility being experienced within each individual hospital setting (Guidroz, Burnfield-Geimer, Clark,

Schwetschenau, &Jex, 2010). Lewis and Malecha (2011) used the NIS to measure the impact of workplace incivility. Their research determined that workplace incivility occurring from direct supervisors directly correlated with decreased productivity.

Nursing as an Oppressed Group

Nurses are often described as an oppressed group that struggle with control amid physicians, administrators, and nurse leaders, leaving those at the bottom to fight amongst themselves for a sense of power (Farrell, 1997; Rowe & Sherlock, 2005; Simons &Mawn, 2010;

Stanley, Martin, Michel, Walton, & Nemeth, 2007). The OppressedGroupBehavior Model

(Roberts, 1983) was designed toexplain the behaviors that occur under these conditions. In this model, members of a group deemed inferior to more powerful groups within their organization develop learnedbehaviorsthat are necessary for survival. Learned behaviors are those that immobilize and mold people based upon the unwillingness to challenge authority and redirection of pent up aggression on their more vulnerable co-workers (Duchscher& Myrick, 2008).Being members of an oppressed group makes nurses more likely to demonstrate behaviors reflective of a power struggle. Some who feel inferior to the dominant group redirect pent-up aggression on

6 fellow nurses rather than risk the consequences of acting on aggression towards the more

powerful groups (Farrell, 1997).

The unexpressed conflict that is created by being an oppressed group is a major factor leading to horizontal violence in the nursing workplace (Freshwater, 2000). The complex structure of the nursing profession also lends itself to creating an environment which fosters

hostility. As leaders emerge from an oppressed group they take on the characteristics of the

more dominant group and further oppress the members of their own group by being controlling,

coercive, and rigid (Roberts, 1983). This type of behavior as exhibited by the emergent leaders of

the oppressed group occurs in the form of horizontal violence. Horizontal violence develops as a

safe way of releasing aggression that is originally felt for the oppressor (Roberts, 1983).

Horizontal violence between nurses has been shown to impact turnover by causing nurses to

leave their positions in order to avoid these abusive situations all together (Cox &Kerfoot, 1990).

New graduate nurses are especially vulnerable to the effects of oppressed group behavior

(Dushscher& Myrick, 2008).

Burnout

Burnout is defined as a psychological syndrome of physical and emotional exhaustion

that can involve the development of a negative self image, negative attitudes about the job, and

loss of concern for patients and co-workers (Maslach, 2004). Feelings of burnout are commonly experienced among those practicing in the field of nursing.Research has shown that 53% of

Registered Nurses experience burnout (Laschinger et al, 2006). That means that over half of all

nurses will experience burnout at some point in their career.

7 One critical consequence of burnout is cynicism (Laschinger, Leiter, &Gilin, 2009;

Leiter&Maslach, 2009; Leiter, Price, &Laschinger, 2010; Maslach&Leiter, 2008; Rowe &

Sherlock, 2005). Cynicism is defined as an attempt to put distance between oneself and various aspects of the job, which has been found to be an immediate reaction to exhaustion in the workplace (Maslach&Leiter, 2008). Cynicism has also been directly correlated with nursing attrition.In one recent study, Leiter andMaslach (2009) found the cynicism dimension of burnout to play a major role in nurses’ intent to leave the job.

Burnout can create feelings of hostility among nurses as well. Occupational burnout has been shown to cause the person experiencing it to vent frustrations on their coworkers (Lazarus

&Folkman, 1984). Venting of frustrations onto others, as harmless as this may sound, can be considered a form of verbal abuse. Verbal abuse can be any communication that the person on the receiving end considers to be cruel criticism (Cox, 1991). Much research has shown that burnout and the behavior it creates in its wake can have devastating effects on self-esteem, job satisfaction, patient care and critical errors, as well as productivity and general workplace morale

(Aiken et al., 2002; Cox, 1991; Cox &Kerfoot, 1990; Rowe & Sherlock, 2005).

Nurse Retention

The nursing shortage has been of particular interest in recent years due to concerns regarding an adequate supply of caregivers and the potential impact upon patient care (Aiken et al., 2002; Finlayson, Aiken, &Nakarada-Kordic, 2007; Nantsupawat,Srisuphan, Kunaviktikul,

Wichaikhum, Aungsuroch, & Aiken, 2011; Needleman, Buerhaus, Mattke, Stewart,

&Zelevinsky, 2002). Efforts to increase the number of nurses entering the profession have had success (Auerbach, Buerhaus&Staiger, 2011). However, the pending retirement of a large

8 portion of the nurse workforce, and an aging population,will increase the demand for qualified

caregivers. This also necessitates that efforts be initiated to ensure that nurses remain in the

workforce.The retention of new graduate nurses, in particular, is critical since these nurses will provide the foundation for a sustainable future workforce (Cowin&Hengstberger-Sims, 2006).

Current nurse retention strategies include a focus on fostering healthy work environments and facilitating transition into the practice environment through the use of professional socialization programs such as multi-stage nurse orientation and residency programs.To foster a healthy work environment low job satisfaction, high stress, heavy workload, burnout, and relationships with co-workers need to be considered (Cowin&Hentsberger-Sims, 2006;

Laschingeret al., 2010; Leiter&Maslach, 2009; McKenna et al., 2003).

Considerable research has been conducted to measure the influence of the work environment upon job satisfaction and retention (Laschinger, Finegan&Shamian, 2001a;

Laschinger, Shamian& Thompson, 2001b). Workplace empowerment has emerged as a critical variable (Laschinger, Finegan, Shamian&Wilk, 2004).Brown and Kanter (1982) describe empowerment as including four components: access to information, access to resources, access to support, and opportunities for growth. In a recent study on empowerment, it was revealed that an empowering environment significantly reduced intention to leave the profession (Laschinger et al., 2009).

Additional studies have been undertaken to identify interventions to improve job satisfaction and retention. For example, as related to bullying, participants in one studyindicated that helpful strategies to minimizebullying were employee reward systems, valuing diversity among employees, team building exercises, and Employee Assistance Programs (MacIntosh,

9 2006). In another, bullied nurses with a good workplace support system had considerably lower

scores on the propensity to leave and depression scales than those who had little to no support

(Quine, 2001).

New Graduate Nurse Perception of the Work Environment

One of the most important groups to consider when looking at the impact of incivility is the new graduate nurse population. According to a recent study by Auerbach et al. (2011), the

number of young Registered Nurses has been growing steadily over the past decade at a rate not

seen since the 1970s. If the nursing profession can maintain this trend it is likely that the

predicted shortage of nurse can be abated. However, in order to sustain this surge in supply,

these new nurses need to be retained in the workforce.

In the 1980s, 35–60% of new graduates were leaving their employment within the first

year after graduation (Beecroft, Dorey, &Wenton, 2007). In a more recent study by Rudman andGustavsson (2010), it was found that during the first three years of practice one-fifth of new graduate nurses experience extremely high levels of burnout with accompanying depressive symptoms and intention to leave the profession. Although nursing has been growing at a rapid rate it seems that retention of new graduates is still a problem.

It is important to understand what new graduates perceive in their first year of practice and what makes them decide to leave or stay. One study surveyed nurses within their first year of practice and found that 34% of respondents experienced rude, abusive, or unjust criticism, 41% were given too much responsibility without supervision, and 66% found the particular incident to be severely distressing (McKenna et al., 2003). Another study found that new graduates who felt

10 their work environment provided a strong sense of communitywere less likely to experience

burnout and intent to leave (Cho, Laschinger, & Wong, 2006).

Another important consideration in retention of new graduate nurses is the effect of the

generational differences among nurses. Cognizance of generational differences has been

demonstrated as important in promoting successful socialization and retention of the upcoming

generation of nurses (Leiter, Price, &Laschinger, 2010). McKenna et al. (2003) determined that

nurses under 30 years of age were more likely to feel undervalued, unsupported, and overwhelmedin comparison to nurses who are over 30 years of age.

Many new nurses have found the first year of practice to be the most overwhelming. It is a major transition from supervised practice as a student to having the responsibility of independent patient care(Evans, Boxer, &Sanber, 2008; Kelly & Ahern, 2007; Laschinger et al.,

2010; McKenna et al., 2003). One major strategy suggested to improve overall satisfaction and retention during the transition period is graduate nurse residency programs. The 12-18 month duration of the transition support program was considered to be comforting to the new graduate nurse by providing a chance to develop confidence and adapt to the responsibility of the

Registered Nurse (Evans et al., 2008).

Transition Programs

Concern regarding nurse retention, especially amongst new graduates has sparked an

interest in the further development of graduate nurse transition programs. Such programs are

intended to acculturate the new graduate nurse by improving competency, providing peer support

groups, and mentoring (Altier&Krsek, 2006; Beecroft, Santner, Lacy, Kuntzman, &Dorey, 2006;

Kowalski & Cross, 2010; Ulrich, Krozek, Early,Ashlock, Africa, &Carman, 2010). These

11 transition programs were not designed to specifically address workplace incivility, but it has been suggested that the use of such programs may reduce the experience of incivility. They are intended to assist the new graduate with the development of necessary skills that allow them to adapt to their new environment.

Mentor and preceptor programs were developed to reduce the stress of the new graduate by providing regular guidance and support at the point of care (Beecroft et al., 2006; Evans et al.,

2008). Most programs provided up to 6 months of preceptor support, which was found to be just enough time for the nurse to learn basic survival skills (Kowalski & Cross, 2010). Graduate nurses were found to have high levels of stress during their first 6 months of employment related to work environment frustrations, uncertainty associated with the desire to be independent, and inconsistent support from coworkers (Fink, Krugman, Casey, & Goode, 2008).

Although mentoring and preceptor programs were found to be successful, residency programs were developed to further enhance the new graduate experience. One-year programs were developed to provide more time for the new graduate nurse to acculturate and learn critical nursing skills. In addition to models developed to meet the needs of individual organization, several nationally implemented models exist. The one yearUniversity HealthSystem

Consortium/American Association of Colleges of Nursing (AACN, 2008) postbaccalaureate nurse residency program was developed to enhance the critical thinking skills and improve patient care quality outcomes using an evidence guided approach. Developed to meet the needs of transitioning baccalaureate nurses, participants demonstrated a 95.6% one-year retention rate.

The one year Versant Residency program was developed toassist BSN prepared nurses in transitioninginto their role as a professional nurseby incorporating case studies, structured

12 clinical immersion one on one with a preceptor, structured mentoring for each new graduate, and competency validation(Ulrich et al., 2010). These aspects of the residency program were created to reduce new nurse turnover, improve nursing skills competencies, improve job satisfaction, and improve self-confidence. The Versant RN residency program has decreased first year turnover rate from 36% to 8% in BSN prepared nurses (Versant, 2012).

13 Method

A systematic review of the literature associated with the concepts of nurse burnout, bullying, and horizontal violence among new graduate nurses was conducted. Research articles were obtained from MEDLINE- EBSCOhost, PsycInfo, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Abstracts were surveyed for relevance and applicability to this review.

Inclusion criteria consisted of:

• Newly graduated Registered Nurses

• Peer reviewed research articles

• Articles published between 2002 to 2012, focusing mainly on those published within

the last 6 years

• Written in the English language

Exclusion criteria consisted of:

• Articles that focus only on one subspecialty of nursing rather than nursing as a whole

• Other occupations in the medical field

• Literature reviews or essays

• Those written in Non-English languages

Search terms used were:

• New graduate nurs*

• Programs

• Incivility

• Transition

14 • Burnout

• Oppressed group behavior

• Horizontal violence

• Lateral Violence

• Retention

• Bullying

In addition, the Internet was used to obtain reports from professional organizations such

as the American Association of Colleges of Nursing (AACN), The Joint Commission on

Accreditation of Hospital Organizations (TJC), the National Council of State Boards of Nursing

(NCSBN), and the Versant RN residency program. The reference lists from articles and reports obtained through the above methods were also screened to identify other pertinent titles not identified during the initial search. Refer to Figure 1 for the process of limiting research to the selected articles for this review. The quality of the selected articles was assessed initially through the use of the Pyramid of Evidence and Questions to Consider When Appraising Nursing Studies

(Schmidt & Brown, 2012). The quality of qualitative articles wasfurther assessed using the Rapid

Critical Appraisal Checklist for Qualitative Evidence (Fineout-Overholt&Melnyk, 2009). The quality of quantitative articles was further assessed by adapting the Rapid Critical Appraisal

Checklist for Cohort Studies to apply to a nursing population rather than to a patient population

(Fineout-Overholt&Melnyk, 2009).

15 Findings

Sixteen studies related to incivility and programs developed to assist transitioning new

graduate nurses were included in this literature review. Included studies were evaluated for

determinants of incivility and the recommended interventions to reduce work place incivility as

it relates to the experience of new graduate nurses. Within this section examination of these

studies (Table 1) will be analyzed.All studies included were published within the past 10 years.

Thirteen of the 16 articles were published within the last 6 years. All reports included a

qualitative, descriptive component. Six of the 16 articles were longitudinal studies

(Altier&Krsek, 2006; Fink et al., 2008; Grindel&Hagerstrom, 2009; Kelly & Ahern, 2008;

Kramer,Halfer, Maguire, &Schmalenberg, 2012; Ulrich et al., 2010). All of the studies included some type of survey or questionnaire with the exception of two that were based on a face-to-face

interview with each participant (Evans et al., 2008; Kelly & Ahern, 2008). Three of the 16

studies included both a survey as well as open-ended questions (Roche, Lamoureux, &Teehan,

2004; Rosenfeld, Smith, Lervolino, & Bower-Ferres, 2004; Stanley, Martin, Michel, & Nemeth,

2007). In 5 of the 16 studies between 46-77% of the participants ranged from 20 to 30 years of age (Beecroft et al., 2006; Kelly & Ahern, 2008; Kowalski & Cross, 2010; McKenna et al., 2003;

Ulrich et al., 2010). Another 5 of the 16 articles stated the median age of participants to be between 26.3 and 30.66 years (Altier&Krsek, 2006; Fink et al., 2008; Grindel&Hagerstrom,

2009; Peterson,McGillis Hall, O’Brien-Pallas, &Cockerill, 2011; Smith et al., 2010;). Ten of the

16 studies had a majority of participants (more than 50%) with a bachelor’s degree in nursing

(Altier&Krsek, 2006; Beecroft et al., 2006; Fink et al., 2008;Kelly & Ahern, 2008; Kowalski

16 &Cross, 2010; Kramer et al., 2012; Peterson et al., 2011; Rosenfeld et al., 2004; Smith et al.,

2010; Ulrich et al., 2010).

All of the studies had a sample that consisted of only new graduate nurses with the exception of four studies with a sample consisting of Registered Nurses who had varying levels

of experience (Evans et al., 2008; Kramer et al., 2012; Laschinger et al., 2009; Stanley et al.,

2007). Although these studies did not meet the inclusion criteria of new graduate nurses, they

were selected for inclusion based on data demonstrating the impact of workplace incivility.

Kramer et al. (2012) studied the impact of a healthy work environment as it related to new

graduate retention, but first used a separate population of experienced nurses to measure the

health of the work environment. Evans et al. (2008) included a mixed sample of both new

graduate nurses and experienced nurses. This study was included because it explained the new

graduate nurse experience from both the new graduate nurse and the experienced nurses who

interacted with them during the transition. Laschinger et al. (2009) was included in order to

demonstrate the magnitude of incivility in nursing and how it relates to turnover. Stanley et al.

(2007) included vital information as to how lateral violence (a parallel term for horizontal

violence) can be measured and suggestions as to how it can be controlled.

One study met exclusion criteria as it did have a large portion of surgical nurses, which

was considered to be a limitation (Rosenfeld et al., 2004). It was included as it offered significant data related to the importance of social support in transitioning the new graduate.

Location of these studies included the United States, Australia, New Zealand, and Canada.

Sample sizes ranged from 6,000 nurses who completed a residency program (Ulrich et al., 2010)

17 to 13 newly graduated Registered Nurses who were interviewed prior to employment, one

month, and 6 months postemployment (Kelly & Ahern, 2008).

Workplace Incivility

Seven of the 16 articles discussed workplace incivility (bullying and horizontal/lateral

violence) as it relates to unit culture (Evans et al., 2008; Kelly & Ahern, 2008; Kramer et al.,

2012; Laschinger et al., 2009; McKenna et al., 2003; Smith et al., 2010; Stanley et al., 2007).

McKenna et al. (2003) examined the prevalence of horizontal violence experienced by first year

nurses by surveying 551 new nurses in New Zealand. Over half (58%) of the participants

reported being undervalued by other nurses, 34% reported having learning blocked, 20% felt a

threat of repercussions for speaking out, 34% felt emotional neglect, 38% felt distress about the

particular conflict, 46% felt a lack of supervision, and 17% felt lack of support. Out of the above

incidents, 41% described an incident involving rude, abusive, or humiliating comments and 34%

indicated wanting to leave the profession of nursing as a result of the incident.

Laschinger et al. (2009) surveyed 612 Canadian staff nurses to assess their wellbeing,

work environments, and social relationships at work. Many participants (67.5%) experienced

supervisor incivility, 77.6% experienced co-worker incivility, and 47.3% experienced severe emotional exhaustion as measured by the Maslach burnout scale. Hierarchical multiple linear

regression demonstrated that empowerment, supervisor incivility, and cynicism strongly

predicted organizational commitment.

Stanley et al. (2007) examined the effects of lateral violence by administering a 23-

question survey (4 of which were open-ended questions) to 663 employees of the nursing

workforce in a tertiary care center within the United States. Results determined that 46% of

18 participants reported lateral violence was perceived as very serious, 24% stated that lateral violence was a major cause of stress and tension, 26% witnessed a situation where lateral violence threatened to escalate, 14% stated that lateral violence was a major factor in the decision to leave nursing, and 75% believe these behaviors can be mitigated. Specifically related to new graduate nurses, participants observed that there was undermining of new nurses, with the authors reporting that, “new nurses were tested to see if they could make it in the workplace”

(pg. 1258).

Smith et al. (2010) surveyed 117 new graduate nurses on the effects of workplace incivility and empowerment. Out of the 117 nurses, 90.4% reported experiencing co-worker incivility and 77.8% reported experiencing supervisor incivility. Within this study, co-worker incivility was also found to be a significant predictor of intention to leave the job.

Bullying was found to be a common subject of concern in a qualitative study, which, in part, considered the transition experience of nine new graduate nurses in Australia (Evans et al.,

2008). Of the nine nurses interviewed, the majority indicated that they experienced bullying or horizontal violence. One nurse stated that she had intentions to leave her job because of the bullying and another nurse stated that this led to feelings of not belonging.

Another qualitative study was done in Australia with 13 newly graduated nurses (Kelly &

Ahern, 2008). Six of the participants expressed that they had been ill prepared in nursing school for what they would experience as they transitioned into the culture of the nursing workforce.

Over half of the participants described nurses as “eating their young.” “Eating their young” was defined to include power games, informal hierarchical relationships found in the nurseworkforce,

19 and incivility. Within the first six months of employment, all of the participants described experiencing verbal abuse, bullying, and conflict with other staff members.

While not measuring incivility directly, Kramer et al. (2012) conducted research at 40

Magnet® hospitals to determine the influence of the work environment upon new graduate transition and retention. Hospitals were categorized as having very healthy work environments, healthy work environments, or work environments needing improvement. This was determined through the administration of the Essentials of Magnetism© tool which measured work processes and relationships. Subsequent to this determination, data were collected over three years from newly graduated Registered Nurses. The results indicated that those nursing units with healthier work environments had a statistically significant higher retention rate of newly licensed

Registered Nurses than those with work environments needing improvement. Three years after completing a nurse residency program, those nursing units with a very healthy work environment retained 80% of their new nurses, whereas the work environments needing improvement only retained 68% of their new nurses.

New Graduate Nurse Transition Programs

Thirteen studies discussed transition programs and the impact on the new graduate nurse.

Of the 13studies, three interventional approaches emerged. Categories included residency programs, mentoring through preceptors, and workplace empowerment.

Residency Programs. Six of the 16 studies discuss residency programs as an intervention to improve new graduate nurse retention (Altier&Krsek, 2006; Fink et al., 2008;

Kowalski & Cross, 2010; Kramer et al., 2012; Rosenfeld et al., 2004;Ulrich et al., 2010).

Kowalski and Cross (2010) determined that members of a nurse residency program showed a

20 decreased sense of threat, improved communication and leadership skills, and improved clinical

competency. Ulrich et al. (2010) compared a group of Registered Nurses who completed a nurse

residency program to a control group over a period of 10 years. The study demonstrated that

those involved in a nurse residency program had a decreased turnover rate across the 10-year

period, a higher degree of competency, and a higher degree of self-confidence compared to the control group. Altier and Krsek (2006) administered a job satisfaction questionnaire to

Registered Nurses at their initial hiring and again after completing a one year nurse residency program. The study showed that overall satisfaction remained consistent over the year and that nurse retention was 87% at the end of the program. Fink et al. (2008) administered a questionnaire upon hire, at 6 months, and again at 12 months. Questions were related to comfort/confidence, job satisfaction, and five open ended questions that allowed graduate nurses to discuss their personal experience of the nurse residency program. Results indicated that there were three main areas of concern for the new graduates: feeling alone and overwhelmed, nervousness about being responsible for their patients, and a desire to be respected by the more experienced nurses.

Rosenfeld et al. (2004) surveyed 112 Registered Nurses who had completed a nurse residency program. Of those surveyed, 93% remained in their initial place of employment (same unit and same hospital) and had been employed there for 44 months. The survey demonstrated

that the most valued aspects of the residency program were access to leadership, classroom

orientation, opportunity to interact with peers, and ‘supportive relationships with senior staff’.

This study showed that new graduates had a strong desire to acculturate to the unit.

21 The previously referenced study by Kramer et al. (2012) also confirmed the importance of residency programs, in conjunction with healthy work environments, on nurse retention. Of interest was the additional finding that there was no significant difference in the retention rates for programs which consisted of a transition component only (3 to 6 months), programs with a transition component and some additional support for integration (8 months to 1 year) and those programs which incorporated both transition support (3 months) and integration support (an additional 7 to 12 months).

Mentoringthrough preceptors.Five of the 16 studies demonstrated that mentoring through preceptors and social support addressed new graduate concerns regarding preparation for practice and greatly impacted new graduate nurse retention (Beecroft et al., 2006; Evans et al.,

2008; Grindel&Hagerstrom, 2009; Kelly & Ahern, 2008; Peterson et al., 2011). A study done in

Australia, interviewed 13 bachelor of nursing students prior to employment, at one month, and six months postemployment (Kelly & Ahern, 2008). The authors determined that new graduate nurses felt unprepared for professional practice, lacked social support, and over the first six months of employment, developed awareness to the ‘bullying’ culture of nursing. In another study, interviews with nine newly graduate nurses who had completed a support program in

Australia, indicated that bullying behaviors existed and that universities did not prepare new graduates to manage this behavior (Evans et al., 2008). This study determined that mentoring programs facilitated feelings of acceptance in new nurses and allowed them to feel comfortable in their new position. Results suggested that a support program of at least 12 months allowed more time for the nurse to properly adapt to the unit.

22 One study surveyed 107 mentees and their mentors to evaluate the effects of a mentoring

program (Grindel&Hagerstrom, 2009). The authors reported that new nurse confidence, job

satisfaction, and intent to stay rose significantly from the time of initiation into the program to 12

months later.Although this would be expected within the first year of practice, this data confirms

that the mentoring program has a positive result. Beecroft et al. (2006) also studied the effects of

a mentoring program by surveying 318 Registered Nurses during the last week of the program.

For the mentees who met regularly with their mentors, 94% stated that the mentor provided

guidance and feedback, 68% thought the mentor was a stress reliever, and 94% clicked with their

mentor.

Peterson et al. (2011) examined the effects of social support on job satisfaction among

232 newly graduated nurses in Ontario, Canada. Lack of social support was determined to

predict job dissatisfaction and intention to leave the job among new nurses. The authors also

reported that new graduate nurses were less likely to indicate intention to leave the job,

suggesting that a support network helped acculturate the new nurse to the unit.

Empowerment

Two of the 16 studies demonstrated the positive effect of empowerment on new graduate

nurse retention (Roche et al., 2004; Smith et al., 2010). Workplace empowerment includes access

to opportunities, information, support, resources, and relationships. Roche et al. (2004) evaluated empowerment through administration of aLikert style questionnaire and group discussion with

67 new graduate nurses and 23 experienced nurses six months after they began orientation.

Results indicated that only 4.5% of participants were unsatisfied with the program.All of the new graduate nurses rated on the 4 point Likert scale that they felt frequently supported, and

23 participants indicated that consistently working with one preceptor was the most important factor

in their orientation. After six months, the retention rate for the participants of this study was

92.5%.

A predictive non-experimental design was used to test the hypothesis that newly graduated nurses who experience high levels of empowerment and low levels of incivility will have higher levels of organizational commitment (Smith et al., 2010). Out of the 117 newly graduated nurses studied, 90.4% reported co-worker incivility, which was found to be a significant predictor of commitment along with structural empowerment. The authors determined

that new nurses who perceived their workplace as having higher levels of structural

empowerment and lower levels of co-worker incivility were more likely to stay at their

organization.

24 Discussion

Incivility is a persistent element contained in the culture of the nurse work environment,

impacting job satisfaction and retention. Newly graduated nurses are especially vulnerable.

Frequently nurse residency and mentoring programs are suggested as an intervention to address

this vulnerability. Findings from this integrated review of the literature suggest that while these

programs may assist with skill acquisition and development of self-confidence, they do little to thwart what these nurses experience. Although recommendations generated from studies that evaluated incivility directed towards new graduates offered that the culture of incivility on

nursing units be directly addressed; it would appear that instead new graduates are provided

strategies and support to assist in adaptation to an uncivil work environment. Outcome data

measuring the effectiveness of transition programs reported high levels of job satisfaction, lower

intent to leave, and elevated feelings of competency. These findings were attributed to skill

acquisition and supportive relationships with preceptors, mentors and peers. Nurses in these

programs were assisted in “acculturation” to the unit by participation in these programs. Studies

that considered the influence of empowerment also demonstrated that nurses who felt

empowered were less likely to be affected by incivility. While developing the skills to manage

the experience of incivility seems to provide a measure of protection for new graduates, it does

little to influence the underlying impact of incivility on nurse job satisfaction and ultimately

nurse retention.

Effect of Workplace Incivility on New Graduate Nurses

Incivility has been a subject of nursing research for several decades. Whether termed

lateral violence, horizontal violence, or bullying, the result is the same. The effect of workplace

25 incivility is nurse burnout and subsequently reduced nurse retention. Research has focused on

describing the nature of incivility, the impact of incivility and testing interventions which

provide those vulnerable to incivility with the skills and self-confidence to address it.

Especially vulnerable to incivility are new graduate nurses. Research has shown that new graduates are often the targets of incivility because they are at the bottom of a power-related hierarchy associated with the unit culture (Evans et al., 2008; Kelly & Ahern, 2008; McKenna et al., 2003; Stanley et al., 2007). This is significant because new graduates use their first year to build confidence in addition to skills (McKenna et al., 2003). Reducing workplace incivility is crucial in this transition period to improve nurse retention and provide for a healthier work environment. When workplaces address unit culture and empower nurses, they demonstrate greater job satisfaction and organizational commitment (Kramer et al., 2012; Laschinger et al.,

2009; Smith et al., 2010).

Influence of New Graduate Nurse Transition Programs on Retention

Although new graduate nurse transition programs have not been found to directly reduce incivility they may assist new graduate nurses in the development of strategies to adapt to it.

These programs focus on teaching new nurses the basic survival skills, which support adaptation

to the nursing unit (AACN, 2008; Ulrich et al, 2010).This technique may provide new graduates

with a buffer to the uncivil experiences they face while transitioning into the work environment.

Residency Programs.Residency programs were found to be especially beneficial as they

not only offered the new nurse time to develop skills in a non-threatening environment that

provided peer and mentor support as they adapted to the unit and gained confidence

26 (Altier&Krsek, 2006; Fink et al., 2008; Kowalski & Cross, 2010). Uniformly, residency programs were associated with higher levels of job satisfaction and nurse retention.

When looking at nurse residencies, a major theme was the importance of new graduate nurses feeling accepted by their co-workers. In particular, they wished to be accepted by the more experienced nurses in their work setting, especially valuing relationships with peers and senior staff (Fink et al., 2008; Kowalski & Cross, 2010; Rosenfeld et al., 2004). Feeling accepted and supported may assist new graduates in overcoming the experience of incivility, but there is no evidence that it affects the incivility these nurses experience.

Mentoring through preceptors.Mentoring programs directly associated with acculturation to the nursing unit have demonstrated an increase in new graduate nurse job satisfaction and decreased turnover. Socialization is an important part of a nurse’s adaptation to the work environment. Nurse preceptor programs can provide assistance in development of both clinical and social skills needed to transition into an established workplace (Evans et al., 2008;

Kelly & Ahern, 2008). They also have been demonstrated to improve job satisfaction and nurse retention (Beecroft et al., 2006; Grindel&Hagerstrom, 2009; Peterson et al. 2011).These programs, like the nurse residencies, provide opportunities for skill-building to address incivility.

They do not address the cause of incivility.

The Importance of Healthy Work Environments

Kramer et al. (2012) reported that nursing units with a healthy work environment retained more nurses than a nursing unit with a work environment needing improvement. Nurse residency programs with healthy work environments had a higher three year retention rate than those with less healthy work environments. This would indicate that residency programs alone do not

27 directly improve nurse retention, and establishes the importance of the work environment.

Similarly efforts to address nurse empowerment as a component of the work environment suggest that the character of the work environment is critical to the effectiveness of nurse retention programs (Kramer et al., 2012; Roche et al., 2004; Smith et al., 2010).

28 Limitations

Limitations include a lack of research which directly assessed interventions intended to reduce the experience of incivility by new graduate nurses. While new graduate nurse transition programs are often suggested as a form of intervention, they too fail to directly evaluate the experience of incivility by new graduates. In addition, comparison between studies is limited by a lack of uniformity in the definition of the concepts considered and thus the measurement of those concepts. Generalizability is limited in that some studies regarding transition programs only included nurses with a BSN degree in the sample even though they hire nurses with both

ASN and BSN preparation. Generalizability, while supported by the international nature of the studies acquired for this integrative review, is also limited by a clear understanding of the impact of culture upon the assessment of incivility and job satisfaction.

29 Nursing Implications

Incivility and its effects on nurses have been investigatedfor over four decades, yet there is limited research on what can be done to address it. Based on these findings, further research should include the identification of strategies to reduce workplace incivility and the measurement of outcomes associated with implementation of those strategies.

In addition, academic curricula intended to provide transitioning new graduate nurses with professional socialization skills should include content that educates students regarding the experience of incivility and techniques to effectively address that experience. In the practice setting, nurse managers should be aware of the prevalence of incivility, assess for its occurrence, and implement solutions within their line of responsibility and authority. Positive work environments and social support from nurse managers are crucial to the retention of new graduates (Laschinger et al., 2009; Peterson et al., 2011; Stanley et al., 2007).

30 Conclusions

While there is a wealth of information describing incivility in the work environment and programs used to acculturate the new graduate nurse, it appears little has been done to directly affect the incivility that new graduate nurses experience. Acculturation efforts may provide an interim solution that addresses the incivility new graduates experience and resultant turnover.

However, it does not address experience of incivility in the work environment, nor the long-term impact upon overall job satisfaction and commitment to both employer and the profession. It is imperative that incivility be addressed and changes initiated to eliminate an organizational and professional culture that deems incivility as an acceptable behavior.

31 Appendix A: Figures

32 Key Search terms used: “new graduate nurs*” + retention Limiters used: Nursing

Studies with relevant material retrieved from CINAHL (n= 370)

Limiters: English language, full text only, between 2002-2012, peer- reviewed, research articles.

Studies retained after limiters added (n=80)

Addition of various combinations of key search terms: ‘programs,’ ‘bullying,’ ‘incivility’, ‘burnout’, ‘transition’, ‘oppressed group behavior’, ‘horizontal violence’, ‘lateral violence’, and ‘retention’

Studies retained after various combinations of additional search terms added (n=22)

Studies were reviewed and relevant studies were chosen for inclusion in thesis. (n= 16)

Figure 1: Literature Selection Method

33 Appendix B: Tables

34 Table 1: Table of Evidence

ARTICLES DESIGN POPULATION INTERVENTION FINDINGS LIMITATIONS IMPLICATION S Kramer, M., Longitudinal 5,316 new graduates The Essentials of Experienced 5 of the hospitals Healthy work Halfer, D., quantitative in RN roles at 28 Magnetism (EOM) nurses that were unable environments Maguire, design with a magnet hospitals. tool was developed indicated very to provide 3-year make a difference P.&Schmalenb descriptive to measure the healthy work retention data in nurse erg, C. (2012). component Employed during work process and environments may have retention. Newly Impact of 2006-2008. relationships that (VHWE) on significantly licensed nurses healthy work constitute healthy 54% of the impacted the data working in environments Education: work environments. units, healthy because they were healthy work and multistage BSN: (n=3,188) The EOM was work all academic environments are nurse ADN: (n=1,253) administered to environments hospitals. more likely to residency Diploma: (n=73) experienced nurses (HWE) on Academic stay. programs on MSN: (n=41) on the units in the 28%, and work hospitals have retention of selected hospitals to environments been shown to newly licensed Hospitals were determine whether needing have a lower RNs. The selected based on a these hospitals had improvement retention rate than Journal of nurse residency healthy work (WENI) on community Nursing program that was environments or 18%. hospitals. Administration operative for at least 3 work environments , 42(3), 148- years. needing Retention There is a lack of 159. improvement. rates: definition in what For EOM: 12,233 VHWE= constitutes a experienced nurses Data was collected 6 mo: 97% VHWE, HWE, working on 717 units on the retention rate 1 y: 92% and WENI. in 40 hospitals. of new graduate 2 y: 91% nurses at 6 months, 3 y: 80% 1, 2, and 3 years HWE= post hire based on 6 mo: 92% the number of 1 y: 87% employed months. 2 y: 79%

35 ARTICLES DESIGN POPULATION INTERVENTION FINDINGS LIMITATIONS IMPLICATION S 3 y: 77% WENI: 6 mo: 83% 1 y: 76% 2 y: 71% 3 y: 68%

Peterson, J., Exploratory 232 newly graduated Surveys mailed to Mean job This information Support within McGillis Hall, cross- nurses with an average the homes of new satisfaction is only the workplace L., O’Brien- sectional of only 15 months in RNs to measure job was a 16.2 on a generalizable to was found to Pallas, L., survey their current position demand, self- scale of 3-21. the population of negatively impact Cockerill, R. in Ontario, Canada. efficacy, job Mean intention new nurses in both intention to (2011). Job satisfaction, to leave the job Ontario, Canada leave the job and satisfaction and Age range: 22-53 support, and was a 6.8 on a who speak job satisfaction. intentions to (average 26.8 years) propensity to leave. scale of 3-15 English and Offering support leave of new Job demands were (higher scores received their in the workplace nurses. Journal Average 18 months measured with a reflect higher education in is crucial in of Research in experience seven-item scale intention to Canada. In order retaining new Nursing, 16(6), measuring leave the job). to have a more graduate nurses. 536-548. Majority female with employees’ Support and accurate bachelor’s degree. perceptions of the self- efficacy understanding of quantity of work negatively the relationship Over half med- assigned on a scale affect job between the surg/teaching hospital of 1 to 5. satisfaction. variables the Personal Efficacy Effect of social study would need Beliefs Scale, a 10- support also to be replicated in item scale with negatively other populations responses given on affected as well as a six-point intention to longitudinally.

36 ARTICLES DESIGN POPULATION INTERVENTION FINDINGS LIMITATIONS IMPLICATION S Likertscale. leave the job. Assessing global New graduate job satisfaction nurses working measured by a in a teaching seven-point Likert hospital were scale. less likely to The Propensity to report Leave Scale. intentions to leave the job. Ulrich, B., Longitudinal 6,000 new graduate Data was collected Competence Many hospitals Both new Krozek, C., nurses who completed from the and self- did not have graduate nurses Early, S., the Versant RN organizations that confidence accurate data on and their Ashlock, C.H., Residency. participated in the were turnover rate organizations that Africa, L.M., Organizations ranged Versant residency accelerated. At before the they work for & Carman, from small, rural programs. Turnover 12 months implementation benefit from M.L. (2010). hospitals to large rates were preceding the of the nurse nurse residency Improving health care systems measured at months program residency programs. New retention, with cohort sizes from 12, 24, 36, 48, and turnover rate program. Only nurses are less confidence, 4 to 110 residents. 60 and compared to was 20% lower the hospitals that likely to leave the and pre-program than pre- reported both 12 profession competence of Education: turnover rates. program and 24 month (decrease new graduate Diploma (1%) Measure or nurse turnover rates. pre-Versant new turnover) with nurses: Results Associate Degree competency. graduate turnover the Versant nurse from a 10-year (45%) Nurse Job were able to be residency longitudinal Baccalaureate degree Satisfaction scale. compared to the program. New database. (51%) Work Satisfaction actual turnover graduate nurses Nursing Master’s degree (2%) Scale. data. have also been Economics, Skills Competency shown to have 28(6), 363-375. Age: Self Confidence better job Less than 23 years Survey. satisfaction. (15%) Leader

37 ARTICLES DESIGN POPULATION INTERVENTION FINDINGS LIMITATIONS IMPLICATION S 23-30 years (52%) Empowering 31-40 years (21%) Behavior Scale. 41-50 years (9%) over 50 years (3%) Kowalski, S. & Qualitative Participants included Clinical The findings The small number Nurse residency Cross, C. L. 55 nurse residents competencies, showed of subjects who programs can (2010). consisting of both anxiety, stress, improved have completed improve nurse Preliminary BSN and ADN new professional clinical the program retention and outcomes of a graduate nurses that transition and competency limits this study. decrease local residency entered the nurse retention were throughout the This study also incivility in the programme for residency program measured on nurses program, a lacks a control workplace. new graduate between July 2007 and who completed the decreased group for Registered June 2008. nurse residency sense of threat, comparison. Nurses. program. and improved Because this Journal of Age: Pagana’s Clinical communication program is fairly Nursing 21-25 (n=14) Stress and leadership new, more data Management, 26-30 (n=20) Questionnaire. skills. The first would need to be 18, 96-104. 31-35 (n=6) year retention assessed long 36-40 (n=8) Spielberg’s State- rate was 78%, term to see 41+ (n=7) Trait Anxiety and the second whether a true inventory. year was 96%. relationship exists Gender: among the Female (n=46) Casey-Fink variables. Male (n=9) Graduate Nurse Experience Survey. Ethnicity: White (n=31) Asian (n=16) African American (n=5) Hispanic (n=3)

38 ARTICLES DESIGN POPULATION INTERVENTION FINDINGS LIMITATIONS IMPLICATION S

Nursing Degree: BSN (n=32) ADN (n=23) Smith, L.M., Predictive 117 Newly graduated Structural Structural Small sample size Specific Andrusyszyn, non- nurses (less than 3 empowerment was empowerment due to mailed strategies are M.A., experimental years experience) measured using the and coworker survey. Response necessary in &Laschinger, design. working in acute care Conditions for incivility were bias due to self- order to decrease H.K. (2010). hospitals. Work Effectiveness both found to report incivility and Effects of Questionnaire-II. be significant questionnaire. disempowerment workplace Age: Psychological predictors of Recall bias as in the workplace incivility and Average 27.12 years Empowerment job participants may and retain new empowerment Questionnaire. commitment, have found it graduate nurses. on newly Gender: Workplace but difficult to recall graduated Female (n=112) Incivility Scale. psychological initial experiences nurses’ Male (n=5) Affective commitment as new graduates. organizational Commitment Scale. was not. commitment. Specialty: Journal of Critical care (n=52) Nursing Maternity (n=21) Management, Med/surg (n=41) 18, 1004-1015. Mental health (n=3)

Education: College diploma (n=2) BSN (n=112) MSN (n=2)

Years experience: Average 2.16 years Grindel, C.G. Longitudinal 14 hospitals from Evaluation was New nurse There was a high Mentoring can

39 ARTICLES DESIGN POPULATION INTERVENTION FINDINGS LIMITATIONS IMPLICATION S &Hagerstrom, design around the country collected 4 times confidence participation rate make a difference G. (2009). participated: Northeast over a 12 month increased for the first in the retention of Nurses (n=4), South (n=10), period for both within the first survey but new graduate nurturing North Central (n=3), mentors and 6 months. participation nurses. nurses: West (n=1). Data was mentees. Intent to stay at dramatically Outcomes and received from 96 Intent to stay job their current dropped by the 4th lessons mentees and 129 diagnostic survey. job peaked at survey. learned. mentors. New nurse the end of 12 Actual causes of MEDsurg confidence scale. months. attrition could not Nursing, 18(3), Mentor age: Nurse job The be documented. 183-194. Average= 41.64 years satisfaction survey. relationship Mentee age: Mentee assessment between Average= 30.66 years of relationship with mentee and the mentor. mentor peaked Mentor gender: Mentors assessment at 6 months Female (n=125) of relationship with then dropped at Male (n=5 the mentee. the end of the Mentee gender: Mentee’s 12 months. Female (n=92) satisfaction with N3 Male (n=4) program. Mentor’s Mentor race: satisfaction with N3 Black (n=7) program. White (n=113) Asian (n=4) Hispanic (n=4) Other (n=1) Mentee race: Black (n=6) White (n=76) Asian (n=5)

40 ARTICLES DESIGN POPULATION INTERVENTION FINDINGS LIMITATIONS IMPLICATION S Hispanic (n=5) Other (n=2)

Mentor education: Diploma (n=21) Associates (n=37) Bachelors (n=55) Masters (n=16) Mentee education: Diploma (n=8) Associates (n=51) Bachelors (n=34) Other (n=2)

Areas of practice include med/surg, critical care, cardiac, OR, labor and delivery, and rehabilitation Laschinger H. Hierarchical 612 Canadian staff Structural 77.6% A longitudinal Demonstrates an K., Leiter M., multiple nurses from 5 empowerment was experienced study would be importance in a Day A. &Gilin linear organizations in two measured through coworker beneficial to positive working D. (2009). regression provinces. the Conditions for incivility and further support environment to Workplace analyses. Work Effectiveness 67.5% the findings. retain nurses. empowerment, Gender: Questionnaire. experienced The study should This is the first incivility, and Female (n=574) Encounters with supervisor also include a study to link burnout: Male (n=31) workplace incivility incivility. larger sample size structural Impact on staff No response (n=7) were measured by 47.3% that is more empowerment nurse the Workplace experienced representative of and burnout with recruitment Age: Incivility Scale. severe burnout. the nursing incivility in the

41 ARTICLES DESIGN POPULATION INTERVENTION FINDINGS LIMITATIONS IMPLICATION S and retention Average =41.3 years Incivility Emotional population as a workplace. outcomes. encounters were exhaustion, whole. Because Perceptions of Journal of Experience: then further rated. cynicism, and the study only work- place Nursing <6 months (n=10) The Emotional supervisor included nurses in incivility are Management, 6-24 months (n=37) Exhaustion and incivility most Canada it is hard related to feelings 17, 302–311. 2-5 years (n=125) Cynicism subscales strongly to say how of empowerment, 6-10 years (n=113) of the Maslach predicted generalizable this burnout, and 11-15 years (n=66) Burnout Inventory turnover is to the retention. 16-20 years (n=82) were used to intentions. American 21-30 years (n=96) measure burnout. population of 30+ years (n=32) Job satisfaction was nurses. No response (n=51) measured by rating 5 aspects of the job. Organizational commitment was measured using the Affective commitment scale. All of the above items were measured on a 7 pointLikert scale. Evans, J., Qualitative Participants consisted A descriptive Three themes The small sample Perceived Boxer, E., descriptive of 9 newly graduated design was arose from the size is a huge strengths and &Sanber, S. design. registered nurses who conducted using analysis: limitation. It is weaknesses of (2008). The had completed a face‐to‐face semi‐ programs unknown to what current support strengths and transition support structured operate in a degree this study programs for weaknesses of program within the interviews. The clinical could be graduate nurses transitional past 12 months and 13 interviews lasted environment generalizable to can further direct support experienced nurses one hour, were which results the larger institutions to programs for that worked with the videotaped, and in population. adapt their

42 ARTICLES DESIGN POPULATION INTERVENTION FINDINGS LIMITATIONS IMPLICATION S newly new nurses. These 22 later transcribed. unsupportive programs Registered nurses came from Interviews were behavior appropriately to Nurses. seven different developed to toward new better suit the Australian hospitals and represent explore the graduate graduate nurse. Journal of both small and large perceived strengths nurses, nurse Advanced facilities in Sydney, and weaknesses of unit managers Nursing, 25(4), Australia. support programs influence the 16-22. provided for new experiences New graduate nurse graduate nurses in ofnew graduate (n=9) the workplace. nurses, and Experienced nurses transition who worked with support these new nurses programs are (n=13) provided to redress the perceived inadequacy of university preparation for Registered Nurses. Fink, R., Qualitative 434 gradate nurse Multiple online 24% were Overall response Adds to the body Krugman, M., residents hired surveys, including stressed at rate was high but of research do Casey, K., & between May 2002 the Casey-Fink baseline, 11% throughout the perceive stress in Goode, C. and September 2003 Graduate Nurse at 6 months, length of the adjusting to the (2008). The and had fully Experience and 18% at 12 study some role of the new graduate nurse completed the one- instrument. months. participants nurse. experience: year nurse residency The participants 10% believed dropped out or GNs express the Qualitative program. took the survey they were failed to answer need for having a residency over 3 periods independent at all questions. nurse program Average participant: during the first year performing Poor attrition preceptor/mentor

43 ARTICLES DESIGN POPULATION INTERVENTION FINDINGS LIMITATIONS IMPLICATION S outcomes. 26 year old, of transition into skills at 6 could affect the for the entire first Journal of Caucasian, with BSN practice: at time of months and 7% results. year of practice Nursing preparation. hire, 6 months, and at 12 months. rather than for Administration, 12 months on 42% were still only 6 months. 38(7/8), 341- BSN required by completion of the having 348. residency program. 1-year program. transition Questions were difficulties at Specialty: answered based on 12 months, Ranged from critical a Likert scale. expressing care, med/surg, being oncology, psychiatry, overwhelmed rehabilitation, and with the women’s services. workload and nurse to patient ratios. Nurse manager support and feedback was identified as a top way to facilitate transition. Many suggested the need for a consistent preceptor. Kelly, J. & Phenomenol 13 students enrolled in Participants were Before The experiences Increasing Ahern, K. ogical a Bachelor of Nursing interviewed in their employment, of such a small awareness that (2008). longitudinal program at an final semester and students had sample size nursing culture Preparing study Australian University. during employment positive cannot be can influence

44 ARTICLES DESIGN POPULATION INTERVENTION FINDINGS LIMITATIONS IMPLICATION S nurses for in the hospital perceptions. assumed to be recruitment and practice: A Age: setting. Data was After one representative of retention of new phenomenologi 20-30 (n=10) collected at three month of all new graduate graduates. Need cal study of the 30-40 (n=1) intervals: prior to employment, nurses. The study for new graduate new graduate 40+ (n=2) employment, one participants was only nurses to be in Australia. month, and six felt that cliques conducted on educated and Journal of Employment: months excluded them nurses from one prepared to deal Clinical Private hospital (n=7) postemployment. and provided a particular school with foreseeable Nursing, 18, Public hospital (n=6) limited amount of nursing in stressors in the 910-918. of assistance Australia. One workplace. Experience: with participant also 1 area (n=1) performing relocated to 2 areas (n=6) new tasks. Canada during the 3 areas (n=3) study possibly 4+ areas (n=3) affecting the data.

Gender: Female (n=11) Male (n=2)

Stanley, K.M., Descriptive 663 employees within Surveys were 46% reported Non-random Horizontal Martin, M.M., with the nursing workforce completed online that lateral convenience violence effects Michel, Y., Quantitative (601 of which were by the participants. violence was sample was used. nurse retention Walton, J.M., and Registered Nurses) at 23 questions were perceived as Those that and stress on the & Nemeth, Qualitative a single tertiary care asked (19 of which very serious or responded to the job. L.S. (2007). components center in the northeast had ordered somewhat 4 open ended Mediators such Examining United States. responses and 4 of serious. questions could as preceptors or lateral violence which were open- 24% stated that have strong nurse managers in the nursing RNs (n=601) ended). lateral violence opinions about could be used as workforce. was a major lateral violence, an important

45 ARTICLES DESIGN POPULATION INTERVENTION FINDINGS LIMITATIONS IMPLICATION S Issues in Age: cause of stress skewing the outlet to reduce Mental Health 20-30 (n=109) and tension. results. the issues Nursing, 23, 31-40 (n=168) 26% witnessed associated with 1247-1265. 41-50 (n=214) a situation lateral violence. 51-60 (n=144) where lateral Units could 61-70 (n=15) violence benefit from >70 (n=1) behavior programs that No response (n=12) threatened to could mitigate escalate. 14% horizontal Gender: stated that violence. Female (n=604) lateral violence Male (n=47) was a major No response (n=12) factor in the decision to Race: leave a nursing Asian (n=14) position. 75% African American believe that (n=63) these behaviors Hispanic (n=7) can be White (n=545) mitigated. Other (n=16) Three main Missing (n=18) themes emerged from Specialty: the qualitative Med/surg (19%) open-ended Critical care/ER (16%) questions: Ambulatory (13%) perceived seriousness, oppressors, and mediators. Beecroft, P.C., Qualitative 318 Registered Nurse Survey regarding Mentors Responses Mentorship

46 ARTICLES DESIGN POPULATION INTERVENTION FINDINGS LIMITATIONS IMPLICATION S Santner, S., residents involved in a nurse mentorships provided included only the programs can be Lacy, M.L., nurse residency from 1999 to 2005. guidance and perspective of successful in Kunzman, L., program. Responses were support for mentees and not helping transition &Dorey, F. summarized with more than 90% the mentors. new graduate (2006). New Age: descriptive and facilitated nurses into the graduate <23 (n=59) statistics, and then stress workplace. nurses’ 23-30 (n=186) logistic regression reduction for perception of 31-40 (n=56) was used to see the majority of mentoring: 40+ (n=14) whether the Six-year demographic participants. programme Education: variables predicted evaluation. AA (n=124) successful program Journal of BSN (n=193) outcomes. Advanced Nursing, 55(6), 736-747. Altier, M.E. Prospective, 316 nurse residents McCloskey Mueller The program No control group. Demonstrates &Krsek, C.A. longitudinal Satisfaction survey retained 87% opportunity for (2006). Effects design Age ranged from 21 to to assess job of its residents Only growth in nurse of a 1-year 59 years (average = satisfaction at the end of 1 baccalaureate residency residency 26.34 years) performed before year. nurses. programs and program on job the residency areas for satisfaction and Gender: program and again Most areas of Limited to improvement. retention of Female (n=282) 1 year later. satisfaction inpatient hospital Indicates a need new graduate Male (n=34) Nurse retention was remained the setting. for further nurses. Journal also measured same before research. for Nurses in Race: before and 1 year and after the Online questions Staff Caucasian (n=239) later. nurse are answered Development, African American residency. Two outside of a 22(2), 70-77. (n=30) areas of controlled setting. Hispanic (n=17) satisfaction

47 ARTICLES DESIGN POPULATION INTERVENTION FINDINGS LIMITATIONS IMPLICATION S Asian (n=18) decreased Native American (satisfaction (n=1) with praise and Other (n=11) satisfaction with Education: professional Previous bachelors opportunities). (n=58) Associates (n=19) Masters (n=20) No prior degree to nursing school (n=237) Roche, J.P., Qualitative 67 new graduate Evaluation of the The most This is a Developing a Lamoureux, E., nurses and 23 empowerment important relatively small strong and &Teehan, T. experienced nurses model. Support was element in sample size and empowering (2004). A entering orientation at measured on a 4 graduate nurse only includes relationship partnership a Massachusetts pointLikert scale satisfaction members from between new between hospital. and qualitative data was their one hospital. The graduate nurses nursing was obtained relationship test was and preceptors education and through a support with their performed after impacts new practice: Using group discussion. preceptor. only 6 months of graduate nurse an the program. For satisfaction. empowerment better accuracy it model to retain should be tested new nurses. again at 1 and 2 Journal of years. Nursing Administration, 34(1), 26-32. Rosenfeld, P., Qualitative 112 participants of a Surveys were The most Only represents New RNs benefit

48 ARTICLES DESIGN POPULATION INTERVENTION FINDINGS LIMITATIONS IMPLICATION S Smith, M.O., descriptive nurse residency mailed out. valuable nurses from one from the Lervolino, L., program in New York Respondents were experiences hospital in New elements of a & Bower- completed the survey. to rank satisfaction perceived by York. Sample nurse residency Ferres, S. with elements of the nurses size consisted program that can (2004). Nurse Specialty: the nurse residency included largely of surgical engage the new residency Surgical (54.6%) program on a 1 to 5 experience, nurses, which hire. This program: A 5- Medicine (29.6%) Likert scale. They support, access may have created includes year evaluation Small number in ICU, were also asked to to leadership, a bias. Data was knowledge of the from the pediatrics, obstetrics, state what they and obtained well institution participants’ and rehabilitation liked most and least relationships. after nurses had through perspective. about the program. Out of the completed the orientation, The Journal of All were hired with Two open ended open-ended nurse residency relationships with Nursing BSN preparation questions were questions a program, which mentors, and Administration, included asking for major theme could also create access to 34(4), 188-194. Average length of recommendations emerged where bias. leadership. Being employment was 44 for revisions and most nurses grouped with months (ranging from comments about commented other nurses 1 to 6.4 years) features of the that the having a similar program. preceptor experience better 93% still employed at program acclimates nurse the institution offered was residents into the ineffective hospital setting. when scheduled with several different preceptors. To be more beneficial they recommended having one

49 ARTICLES DESIGN POPULATION INTERVENTION FINDINGS LIMITATIONS IMPLICATION S preceptor who was able to dedicate more time to the new graduate. McKenna, Qualitative 551 new graduate Survey regarding Over half The study was Horizontal B.G., Smith, descriptive nurses in New Zealand interpersonal reported being only done in New violence exists N.A., Poole, within their first year conflict amongst undervalued by Zealand therefore and is a common S.J., & of practice. nurses. other nurses. it is difficult to experience by Coverdale, J.H. If nurses responded 31% say how new graduate (2003). Specialty: that yes they had experienced generalizable this nurses. Some Horizontal Medical wards been exposed to being would be to the type of assistance violence: (n=114) workplace incivility undervalued. American or training should Experiences of Surgical wards they were then 17% were population. be offered to help Registered (n=145) asked to rate the blocked of Although the minimize this Nurses in their Other specialties severity of the learning sample size is occurrence. first year of including rehab, experience. opportunities. large, less than Many nurses also practice. obstetrics, pediatrics, 16% felt half of the considered Journal of emergency, OR, and emotional original sample leaving the Advanced ICU (n=164) neglect.16% size participated. profession of Nursing, 42(1), Mental health (n=68) felt distressed nursing in 90-96. Community (n=30) by the conflict regards to the Other (n=22) of others. 23% hostile work felt environment. Gender: overwhelmed This supports that Female (n=513) and given too incivility affects Male (n=32) much nurse retention. responsibility Age: without 20-30 (n=251) appropriate 30-39 (n=138) support. 31%

50 ARTICLES DESIGN POPULATION INTERVENTION FINDINGS LIMITATIONS IMPLICATION S 40-49 (n=130) described a 50+ (n=28) most distressing Ethnicity: incident (41% European (n=458) of these Maori (indigenous to involving rude, New Zealand (n=51) abusive, or Pacific islanders (n=8) humiliating Asian (n=19) comments). Other (n=8) 34% indicated leaving nursing as a result of this incident.

51 References

Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J.,& Silber, J.K. (2002). Hospital nurse

staffing and patient mortality, nurse burnout, and job dissatisfaction. The Journal of the

American Medical Association, 288(16), 1987-1993.

Altier, M.E.,&Krsek, C.A. (2006).Effects of a 1-year residency program on job satisfaction and

retention of new graduate nurses.Journal for Nurses in Staff Development, 22(2), 70-77.

American Association of Colleges of Nursing. (2008). University health system consortium.

Retrieved from http://www.aacn.nche.edu/leading-initiatives/education

resources/NurseResidencyProgramExecSumm.pdf. NursingReport.pdf, accessed on 13

May, 2012.

Auerbach, D.I., Buerhaus, P.I.,&Staiger, D.O. (2011). Registered Nurse supply grows faster than

projected amid surge in new entrants ages 23-26. Health Affairs, 30(12), 2286-2292.

Bae, S., Mark, B.,& Fried, B. (2010).Impact of nursing unit turnover on patient outcomes in

hospitals.Journal of Nursing Scholarship, 42(1), 40-49.

Beecroft, P.C., Santner, S., Lacy, M.L., Kunzman, L.,&Dorey, F. (2006). New graduate nurses’

perception of mentoring: Six-year programme evaluation. Journal of Advanced Nursing,

55(6), 736-747.

Brown, J.C.,&Kanter, R.M. (1982). Empowerment: Key to effectiveness. Hospital Forum, 25, 6-

7.

Cherry, B.,& Jacob, S.R. (2011).Contemporary nursing: Issues, trends, & management (5th

ed.).St. Louis, MO: Mosby Elsevier.

52 Cho, J., Laschinger, H.K.S.,& Wong, C. (2006). Workplace empowerment, work engagement

and organizational commitment of new graduate nurses. Canadian Journal of Nursing

Leadership, 19(3), 43-60.

Cortina, L.M.,&Magley, V.J. (2009). Patterns and profiles of response to incivility in the

workplace.Journal of Occupational Health Psychology, 14(3), 272-288.

Cox, H.C. (1991).Verbal abuse nationwide, Part 1: oppressed group behaviors. Nursing

Management, 22(2),32–35.

Cox, H. C.,&Kerfoot, K.M. (1990).Changing verbal abuse into a syntonic interactive mode: The

nurse manager’s challenge. Nursing Economics, 8(6), 416-417.

Cowin, L.S.,&Hengstberger-Sims, C. (2006). New graduate nurse self-concept and retention: A

longitudinal survey. International Journal of Nursing Studies, 43(1), 59-70.

Duchscher, J.B.,& Myrick, F. (2008). The prevailing winds of oppression: Understanding the

new graduate experience in acute care. Nursing Forum, 43(4), 191-206.

Duffy, E. (1995). Horizontal violence: A conundrum for nursing. Collegian, 2, 5-17.

Evans, J., Boxer, E.,&Sanber, S. (2008). The strengths and weaknesses of transitional support

programs for newly Registered Nurses. Australian Journal of Advanced Nursing, 25(4),

16-22.

Farrell, G.A. (1997). Aggression in clinical settings: Nurses' views. Journal of Advanced

Nursing, 25, 501-508.

Ferns, T.,&Meerabeau, L. (2009). Reporting behaviors of nursing students who have

experienced verbal abuse. Journal of Advanced Nursing, 65(12), 2678– 2688.

53 Fineout-Overholt, E.,&Melnyk, B.M. (2009).Evidence based practice in nursing & healthcare:

A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins.

Fink, R., Krugman, M., Casey, K.,& Goode, C. (2008). The graduate nurse experience:

Qualitative residency program outcomes. Journal of Nursing Administration, 38(7/8),

341-348.

Finlayson, M., Aiken, L.,&Nakarada-Kordic, I. (2007). New Zealand nurses' reports on hospital

care: An international comparison. Nursing Praxis in New Zealand, 23(1), 17-28.

Freshwater, D. (2000). Crosscurrents: Against cultural narration in nursing.Journal of Advanced

Nursing, 32(2), 481-484.

Grindel, C.G.,&Hagerstrom, G. (2009). Nurses nurturing nurses: Outcomes and lessons learned.

MEDsurg Nursing, 18(3), 183-194.

Guidroz, A.M., Burnfield-Geimer, J.L., Clark, O., Schwetschenau, H.M., &Jex, S.M. (2010).

The nursing incivility scale: Development and validation of an occupation-specific

measure. Journal of Nursing Measurement, 18(3), 176-199.

Kelly, J.,& Ahern, K. (2008). Preparing nurses for practice: A phenomenological study of the

new graduate in Australia. Journal of Clinical Nursing, 18, 910-918.

Kowalski, S.,& Cross, C. L. (2010). Preliminary outcomes of a local residency programme for

new graduate Registered Nurses.Journal of Nursing Management, 18, 96-104.

Kramer, M., Halfer, D., Maguire, P.,&Schmalenberg, C. (2012).Impact of healthy work

environments and multistage nurse residency programs on retention of newly licensed

RNs.The Journal of Nursing Administration, 42(3), 148-159.

54 Laschinger, H.K.S., Grau, A.L., Finegan, J.,&Wilk, P. (2010). New graduate nurses’ experiences

of bullying and burnout in hospital settings. Journal of Advanced Nursing, 66(12), 2732-

2742.

Laschinger, H.K.S., Finegan, J.,&Shamian, J. (2001a). Promoting nurses' health: effect of

empowerment on job strain and work satisfaction. Nursing Economics, 19(2), 42-53.

Laschinger, H.K.S., Finegan, J.E., Shamian, J.,&Wilk, P. (2004). A longitudinal analysis of the

impact of workplace empowerment on work satisfaction.Journal of Organizational

Behavior, 25, 527-545.

Laschinger, H.K.S, Leiter, M., Day A.,&Gilin D. (2009). Workplace empowerment, incivility,

and burnout: Impact on staff nurse recruitment and retention outcomes. Journal of

Nursing Management, 17, 302–311.

Laschinger, H.K.S., Shamian, J.,& Thomson, D. (2001b). Impact of magnet hospital

characteristics on nurses' perceptions of trust, burnout, quality of care, and work

satisfaction.Nursing Economics, 19(5), 209-220.

Lazarus, R.S.,&Folkman, S. (1984).Stress, Appraisal, and Coping. New York, NY: Springer

Publishing.

Leiter, M.P.,&Maslach C. (2009). Nurse turnover: The mediating role of burnout. Journal of

Nursing Management, 17, 331–339.

Leiter, M.P., Price, S.L.,&Laschinger, H.K.S. (2010). Generational differences in distress,

attitudes and incivility among nurses.Journal of Nursing Management, 18, 970–980.

MacIntosh, J. (2006). Tackling workplace bullying. Issues in Mental Health Nursing, 27, 665-

679.

55 MacKusick, C.I.,&Minick, P. (2010). Why are nurses leaving? Findings from an initial

qualitative study on nursing attrition.MEDSURG Nursing, 19(6), 335-340.

Maslach, C. (2004).Different perspectives on job burnout.Contemporary Psychology: APA

Review of Books, 49(2), 168–170.

Maslach, C.,&Leiter, M.P. (2008). Early predictors of job burnout and engagement.Journal of

Applied Psychology, 93(3), 498-512.

McKenna, B.G., Smith, N.A., Poole, S.J.,& Coverdale, J.H. (2003). Horizontal violence:

Experiences of Registered Nurses in their first year of practice. Journal of Advanced

Nursing, 42(1), 90-96.

Nantsupawat, A., Srisuphan, W., Kunaviktikul, W., Wichaikhum, O.A., Aungsuroch, Y.,&

Aiken, L.H. (2011). Impact of nurse work environment and staffing on hospital and

quality of care in thailand. Journal of Nursing Scholarship, 43(4), 426-433.

Needleman, J., Buerhaus, P., Mattke, S., Stewart, M.,&Zelevinsky, K. (2002). Nurse staffing and

quality of patient care in the United States. Policy, Politics, & Nursing Practice, 3(4),

306-308.

Peterson, J., McGillis Hall, L., O’Brien-Pallas, L.,&Cockerill, R. (2011).Job satisfaction and

intentions to leave of new nurses.Journal of Research in Nursing, 16(6), 536-548.

Quine, L. (2001). Workplace bullying in nurses.Journal of Health Psychology, 6, 73-84.

Roberts, S.J., DeMarco, R.,& Griffin, M. (2009). The effect of oppressed group behaviors on the

culture of the nursing workplace: A review of the evidence and interventions for

change.Journal of Nursing Management, 17(3), 288-293.

56 Roche, J.P., Lamoureux, E.,&Teehan, T. (2004). A partnership between nursing education and

practice: Using an empowerment model to retain new nurse. Journal of Nursing

Administration, 34(1), 26-32.

Rosenfeld, P., Smith, M.O., Lervolino, L.,& Bower-Ferres, S. (2004). Nurse residency program:

A 5-year evaluation from the participants’ perspective. The Journal of Nursing

Administration, 34(4), 188-194.

Rowe, M.M.,& Sherlock, H. (2005). Stress and verbal abuse in nursing: Do burned out nurses eat

their young? Journal of Nursing Management, 13, 242-248.

Rudman, A.,&Gustavsson, J.P. (2010). Early-career burnout among new graduate nurses: A

prospective observational study of intra-individual change trajectories. International

Journal of Nursing Studies, 48(2011), 292-306.

Schmidt, N.A.,& Brown, J.M. (2012). Evidence-based practice for nurses: Appraisal and

application of research (2nd ed.). Sudbury, MA: Jones & Bartlett Learning.

Simons, S.R.,&Mawn, B. (2010). Bullying in the workplace: A qualitative study of newly

licensed Registered Nurses. AAOHN Journal, 58(7), 305-311.

Smith, L.M., Andrusyszyn, M.A.,&Laschinger, H.K. (2010). Effects of workplace incivility and

empowerment on newly graduated nurses’ organizational commitment.Journal of

Nursing Management, 18, 1004-1015.

Stanley, K.M., Martin, M.M., Michel, Y., Walton, J.M.,& Nemeth, L.S. (2007). Examining

lateral violence in the nursing workforce. Issues in Mental Health Nursing, 23, 1247-

1265.

57 Ulrich, B., Krozek, C., Early, S., Ashlock, C.H., Africa, L.M.,& Carman, M.L. (2010).

Improving retention, confidence, and competence of new graduate nurses: Results from a

10-year longitudinal database. Nursing Economics, 28(6), 363-375.

Versant. (2012). Retrieved from http://www.versant.org/more-about-versant/the-versant-

team.html. Html accessed on 13 May, 2012.

Vessey, J.A., DeMarco, R.,&DiFazio, R. (2010). Bullying, harassment, and horizontal violence

in the nursing workforce: The state of the science. Annual Review of Nursing Research,

28, 133-157.

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