Preventing Stress-Related Ill Health Among New Registered Nurses by Supporting Engagement in Proactive Behaviors-A Randomized Controlled Trial

Interventions that support novice nurses' transition into practice: A realist review

BACKGROUND

Many transition-to-practice programs have been developed to support novice nurses during their first years into practice. These programs report improvements in retention, wellbeing and clinical competence, but the driving mechanisms of these interventions remain largely unclear.

OBJECTIVE

To identify how transition-to-practice programs for novice nurses work and in what contexts they work successfully.

METHODS

A realist review was conducted. Eligibility criteria included intervention studies aimed at novice nurses in their first two years of practice that reported outcomes on organizational or individual nurse level. The underlying theory of included transition-to-practice programs was extracted, and relevant contextual factors, mechanisms and outcomes were explored and synthesized into context-mechanism-outcome (CMO) configurations. The search was limited to studies between 2000 and 2023.

RESULTS

A total of 32 studies were included, evaluating 30 different transition-to-practice programs with a wide range of intervention components including stress management, clinical education, professional and peer support, and ward rotations. Transition-to-practice programs were often designed without a theoretical foundation. Driving mechanisms behind the programs pertained to psychological, professional, and social development. Contextual factors that activated the mechanisms were enabling conditions for mentors and novice nurses, selection and motivation of novice nurses and organizational culture.

CONCLUSIONS

Current transition-to-practice programs primarily focus on the individual and professional development of nurses. However, transition to practice can benefit from a systemic approach that includes development initiatives on the organizational level.

REGISTRATION

PROSPERO ID CRD42021268080, August 15, 2021.

TWEETABLE ABSTRACT

Context and mechanisms determine successful implementation of transition to practice programs for novice nurses. @transitiontopractice @nurseworkforce.

Proactive behaviors and health care workers: A systematic review

BACKGROUND

Proactive behaviors at work refer to discretionary actions among workers that are self-starting, change oriented, and future focused. Proactive behaviors reflect the idiosyncratic actions by individual workers that shape the delivery and experience of professional services, highlight a bottom-up perspective on workers' agency and motivation that can influence organizational practices, and are associated with a variety of employee and organizational outcomes.

PURPOSE

This systematic review aims to understand the various forms of proactive behaviors in health care workers that have been studied, and how these proactive behaviors are associated with employee-level outcomes and quality of care.

METHODS

Systematic review of articles published to date on proactive behaviors in health care workers.

RESULTS

Based on the identification of 40 articles, we find that job crafting, active problem solving, voice, extra-role behaviors, and idiosyncratic deals have been investigated as proactive behaviors among health care workers. Among these, job crafting is the most commonly studied (35% of articles), and it has been conceptualized and measured in the most consistent way, including as individual- and group-level phenomena, and as organizational interventions. Studies on active problem solving, which refers to workers accepting responsibility, exercising control, and taking action around anticipated or experienced problems at work, have not been consistently investigated as a form of proactive behavior but represent 25% of the articles identified in this review. Overall, this review finds that proactive behaviors in health care is a burgeoning area of research, with the majority of studies being cross-sectional in design and published after 2010, and focused on workers' job satisfaction as the outcome.

PRACTICE IMPLICATIONS

Health care workers and managers should consider the distinct influences and contributions of proactive behaviors as ways to improve employee-level outcomes and quality of care.

Gaining acceptance, insight and ability to act: A process evaluation of a preventive stress intervention as part of a transition-to-practice programme for newly graduated nurses

AIM

To investigate how NGNs perceived and applied an intervention for preventing stress-related ill health embedded in a transition-to-practice programme when entering their professional life.

DESIGN

A qualitative exploratory descriptive design was selected for this study to gain insights and perspectives on the adoption and utilization of the intervention.

METHODS

In this qualitative methodology process evaluation, semi-structured and audio-recorded interviews were conducted with a sample of 49 nurses. Data were collected between December 2016 and July 2017, and were sorted in NVivo 12 Plus, followed by thematic analysis.

RESULTS

The analysis resulted in three change processes stimulated by the intervention: (a) Building acceptance of being new; (b) Gaining insight into professional development and health and (c) Practical steps for skills development, healthy habits and better-organized work. In addition to the three themes, barriers that hindered the progression of the processes were also described. Each process influenced the development of the others by stimulating a deeper understanding, motivation to change and courage to act. Several barriers were identified, including the use of cognitively demanding intervention tools, fatigue, high work demands, inconvenient work hours and a hostile social climate on the ward.

CONCLUSION

This process evaluation showed that newly graduated nurses used knowledge from the intervention and adopted new behaviours largely in accordance with how the intervention was intended to work.

IMPACT

When entering a new profession, it is crucial to receive a well-thought-out, structured and targeted introduction to the new professional role, tasks and work group. Nurses stated that the intervention increased their understanding of the role as new nurses and their insight into how to develop skills that promoted better functioning and recovery. The intervention also stimulated the development of new health behaviour and some new learning strategies.

Individual-level interventions for reducing occupational stress in healthcare workers

BACKGROUND

Healthcare workers can suffer from work-related stress as a result of an imbalance of demands, skills and social support at work. This may lead to stress, burnout and psychosomatic problems, and deterioration of service provision. This is an update of a Cochrane Review that was last updated in 2015, which has been split into this review and a review on organisational-level interventions.  OBJECTIVES: To evaluate the effectiveness of stress-reduction interventions targeting individual healthcare workers compared to no intervention, wait list, placebo, no stress-reduction intervention or another type of stress-reduction intervention in reducing stress symptoms.  SEARCH METHODS: We used the previous version of the review as one source of studies (search date: November 2013). We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, CINAHL, Web of Science and a trials register from 2013 up to February 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCT) evaluating the effectiveness of stress interventions directed at healthcare workers. We included only interventions targeted at individual healthcare workers aimed at reducing stress symptoms.  DATA COLLECTION AND ANALYSIS: Review authors independently selected trials for inclusion, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. We categorised interventions into ones that: 1. focus one's attention on the (modification of the) experience of stress (thoughts, feelings, behaviour);  2. focus one's attention away from the experience of stress by various means of psychological disengagement (e.g. relaxing, exercise);  3. alter work-related risk factors on an individual level; and ones that 4. combine two or more of the above.  The crucial outcome measure was stress symptoms measured with various self-reported questionnaires such as the Maslach Burnout Inventory (MBI), measured at short term (up to and including three months after the intervention ended), medium term (> 3 to 12 months after the intervention ended), and long term follow-up (> 12 months after the intervention ended).  MAIN RESULTS: This is the second update of the original Cochrane Review published in 2006, Issue 4. This review update includes 89 new studies, bringing the total number of studies in the current review to 117 with a total of 11,119 participants randomised.  The number of participants per study arm was ≥ 50 in 32 studies. The most important risk of bias was the lack of blinding of participants.  Focus on the experience of stress versus no intervention/wait list/placebo/no stress-reduction intervention Fifty-two studies studied an intervention in which one's focus is on the experience of stress. Overall, such interventions may result in a reduction in stress symptoms in the short term (standardised mean difference (SMD) -0.37, 95% confidence interval (CI) -0.52 to -0.23; 41 RCTs; 3645 participants; low-certainty evidence) and medium term (SMD -0.43, 95% CI -0.71 to -0.14; 19 RCTs; 1851 participants; low-certainty evidence). The SMD of the short-term result translates back to 4.6 points fewer on the MBI-emotional exhaustion scale (MBI-EE, a scale from 0 to 54). The evidence is very uncertain (one RCT; 68 participants, very low-certainty evidence) about the long-term effect on stress symptoms of focusing one's attention on the experience of stress. Focus away from the experience of stress versus no intervention/wait list/placebo/no stress-reduction intervention  Forty-two studies studied an intervention in which one's focus is away from the experience of stress. Overall, such interventions may result in a reduction in stress symptoms in the short term (SMD -0.55, 95 CI -0.70 to -0.40; 35 RCTs; 2366 participants; low-certainty evidence) and medium term (SMD -0.41 95% CI -0.79 to -0.03; 6 RCTs; 427 participants; low-certainty evidence). The SMD on the short term translates back to 6.8 fewer points on the MBI-EE. No studies reported the long-term effect. Focus on work-related, individual-level factors versus no intervention/no stress-reduction intervention Seven studies studied an intervention in which the focus is on altering work-related factors. The evidence is very uncertain about the short-term effects (no pooled effect estimate; three RCTs; 87 participants; very low-certainty evidence) and medium-term effects and long-term effects (no pooled effect estimate; two RCTs; 152 participants, and one RCT; 161 participants, very low-certainty evidence) of this type of stress management intervention.  A combination of individual-level interventions versus no intervention/wait list/no stress-reduction intervention Seventeen studies studied a combination of interventions. In the short-term, this type of intervention may result in a reduction in stress symptoms (SMD -0.67 95%, CI -0.95 to -0.39; 15 RCTs; 1003 participants; low-certainty evidence). The SMD translates back to 8.2 fewer points on the MBI-EE. On the medium term, a combination of individual-level interventions may result in a reduction in stress symptoms, but the evidence does not exclude no effect (SMD -0.48, 95% CI -0.95 to 0.00; 6 RCTs; 574 participants; low-certainty evidence). The evidence is very uncertain about the long term effects of a combination of interventions on stress symptoms (one RCT, 88 participants; very low-certainty evidence). Focus on stress versus other intervention type  Three studies compared focusing on stress versus focusing away from stress and one study a combination of interventions versus focusing on stress. The evidence is very uncertain about which type of intervention is better or if their effect is similar.

AUTHORS' CONCLUSIONS

Our review shows that there may be an effect on stress reduction in healthcare workers from individual-level stress interventions, whether they focus one's attention on or away from the experience of stress. This effect may last up to a year after the end of the intervention. A combination of interventions may be beneficial as well, at least in the short term. Long-term effects of individual-level stress management interventions remain unknown. The same applies for interventions on (individual-level) work-related risk factors. The bias assessment of the studies in this review showed the need for methodologically better-designed and executed studies, as nearly all studies suffered from poor reporting of the randomisation procedures, lack of blinding of participants and lack of trial registration. Better-designed trials with larger sample sizes are required to increase the certainty of the evidence. Last, there is a need for more studies on interventions which focus on work-related risk factors.

Effectiveness of formal onboarding for facilitating organizational socialization: A systematic review

OBJECTIVE

To investigate the effectiveness of formal onboarding programs and practices for new professionals.

INTRODUCTION

New professionals may experience high levels of stress and uncertainty. Formal onboarding programs and practices aim to facilitate the socialization of new professionals by structuring early experiences. However, there is a lack of evidence-based recommendations of how to onboard new professionals.

METHODS

This review considered studies that compares the effect of formal onboarding practices and programs for new professionals between 18-30 years of age (sample mean) to the effect of informal onboarding practices or 'treatment as usual' in professional organizations internationally. The outcome of interest for the review was the extent to which new professionals were socialized. The search strategy aimed to locate both published studies (dating back to year 2006) and studies accepted for publication written in English using the electronic databases Web of Science and Scopus (last search November 9 2021). Titles and abstracts were screened and selected papers were assessed by two independent reviewers against the eligibility criteria. Critical appraisal and data extraction were performed by two independent reviewers using Joanna Briggs Institutes templates. The findings were summarized in a narrative synthesis and presented in tables. The certainty of the evidence was assessed using the grading of recommendations, assessment, development and evaluations approach.

RESULTS

Five studies including 1556 new professionals with a mean age of 25 years were included in the study. Most participants were new nurses. The methodological quality was assessed as low to moderate and there were high risks of bias. In three of the five included studies, a statistically significant effect of onboarding practices and programs on new professionals' adjustment could be confirmed (Cohen's d 0.13-1.35). Structured and supported on-the-job training was shown to be the onboarding strategy with the strongest support to date. The certainty of the evidence was rated as low.

CONCLUSION

The results suggests that organizations should prioritize on-the-job training as a strategy to facilitate organizational socialization. For researchers, the results suggest that attention should be given to understanding how to best implement on-the-job training to ensure strong, broad, and lasting effects. Importantly, research of higher methodological quality investigating effects of different onboarding programs and practices is needed. Systematic review registration number: OSF Registries osf.io/awdx6/.

The Importance of Effective Organizational Socialization for Preventing Stress, Strain, and Early Career Burnout: An Intensive Longitudinal Study of New Professionals

Burnout was originally conceptualized based on experiences of new professionals. Role clarity, task mastery, and social acceptance are recognized as key resources enabling new professionals' management of the challenges of the new profession. However, relations between these resources and stress, strain, and burnout have not yet been thoroughly investigated at professional entry. Increased understanding of these relations could have implications for strategies to prevent burnout. The aim of the study was to investigate within- and between-individual effects over the first months and relations to burnout at one-year post-entry. Data (n = 322) was collected weekly over the first 13 weeks and again 9 months later. Relationships were modelled using a multilevel regression model and correlation analysis. Results showed that on weeks when participants experienced higher role clarity, task mastery, and social acceptance, they reported significantly less stress, and that participants who experienced higher levels of the resources in general, reported significantly less strain. Levels of the resources at three months were related to symptoms of burnout at 12 months. The study findings provide support of the role of task mastery, role clarity, and social acceptance as resources buffering the impact of demands at professional entry on experiences of stress, strain, and burnout.