Ashortage of nurses affects healthcare services around the world (Duffield et al, 2014). According to the World Health Organization's (WHO) Global Forum report (WHO, 2013), the healthcare workforce shortage was at 7.2 million in 2013, and the trend is likely to worsen. It is predicted to reach 12.9 million in 2035 if no action is taken (WHO, 2013).
The report identified several fundamental causes for the shortage, including ageing healthcare workforces and the increase in the world's population as a result of longer life expectancy. Subsequently, the number of older populations with specialised health needs is increasing. In turn, this will increase the demand for more health professionals to provide services (Torrington et al, 2014; WHO, 2013). The WHO report highlighted healthcare workforce shortages in broad terms.
Looking specifically at the shortage of nurses, previous studies have identified several reasons for staff to leave the nursing profession. These include unfair treatment of staff (Cho et al, 2009; Zhang et al, 2014) and dissatisfaction with the working environment (Coomber and Barriball, 2007; Chang et al, 2013). Work-life imbalances (Branham, 2005; Leineweber et al, 2014), burnout (Cho et al, 2009; Zhang et al, 2014), and inadequate support for newly qualified nurses (Department of Health (DH) 2010; Torrington et al, 2014) were also factors.
In response to the nurse shortage, recruiting more nursing staff may offer a ‘quick fix’ but on its own it will not solve the problem of the difficulty of staff retention (Torrington et al, 2014). An alternative solution is to enrol newly qualified nurses into preceptorship programmes (PPs) and clinical supervision programmes (CSPs) (DH, 2010; Torrington et al, 2014). PPs are designed to support newly qualified nurses (NQNs) to gain skills, knowledge and confidence for practice, supported by a preceptor; CSPs support nurses to develop professionally and are designed to be open to nurses throughout their career (Happell, 2009; Ford et al, 2013; Apostolidou and Schweitzer, 2017). However, the question remains whether there is evidence that PPs and CSPs support the retention of nurses. Therefore, the authors conducted a literature review to find evidence of PPs and CSPs in retaining NQNs in their clinical practice. Throughout this literature review, the term ‘NQNs’ refers to newly licensed nurses, newly registered nurses and newly graduated nurses, which are the terms used in the various countries in the studies examined.
Research question and search term
This literature review aimed to address the following question. ‘Do preceptorship and clinical supervision programmes support nurse retention in hospital settings?’ A PICo (Population, Interest, Context) strategy was used to frame the research question (Moher et al, 2009). The population (P) are the NQNs, nurse preceptors and nurse supervisors. The interests (I) are PPs, CSPs and staff retention, the context (Co) is hospital settings. The key words from the research question were isolated (Aveyard et al, 2016), and combined with Boolean operators (AND, OR) and formed the following search terms: ‘Staff Nurse OR Staff-Nurse OR Nursing Staff AND Preceptorship Programme OR Preceptorship-Programme AND Clinical Supervision OR Clinical-Supervision AND Staff Nursing Retention AND Hospital’.
Method and design
A systematic literature review method is one of the practical ways to summarise and interpret the result of previous studies (Aveyard et al, 2016), and this review used this method to explore the evidence of PP and CSP on staff retention. The design of this literature review involved three steps. First, the data collection was carried out using a database search on PubMed, CINHAL, Medline, Web of Sciences, and ScienceDirect to identify published literature. Then a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) protocol was used to assess the literature for eligibility and selection for review (see Figure 1). Finally, the selected studies were appraised, summarised, analysed using thematic analysis and the results were presented in themes (Aveyard et al, 2016).
Inclusion and exclusion criteria
This review set several criteria for selecting published literature for data analysis, and publications were included only if the criteria in Table 1 were met.
| Criteria | Inclusion | Exclusion |
|---|---|---|
| Study type | All types of primary research | Literature reviews, editorial comments and letters |
| Participant | All studies with newly qualified nurses, nurse preceptors and nurse supervisors because these groups of participants were the focus of this review | Student nurses and medical students, mental health professionals, physiotherapists, pharmacists, dietitians and other health professionals |
| Outcome | All studies have outcomes that measure the effects of preceptorship and clinical supervision | |
| Year of publication | 2009 to 2019 |
Database search
Figure 1 shows the process of literature identification, screening, eligibility assessment and selection. It started from identifying a total of 124 777 articles, then limiters were applied, and narrowed down to 967 articles. The result was further narrowed to 115 articles after duplications were removed, and the title and abstract screened (852 articles were excluded). Finally, screening of full texts resulted in the inclusion of six articles for review. A total of 109 articles were excluded because the studies involved other health professionals.
Data extraction
The six selected studies were extracted independently by the authors to minimise bias in the data extraction process. Data extraction was compared, and disagreements were discussed. As a result, Table 2 was produced, which shows that the studies originated from several countries and that the review was comprehensive in its coverage. Two studies were from Australia, two from the USA, one from the UK, and one from Ethiopia. The participants were NQNs, preceptors and supervisors, and the studies used various designs: two qualitative studies, one quantitative study, one longitudinal study, one mixed-method study and one observational study. The outcomes of the selected studies measured PP and CSP.
| Author, date, country | Research question or aim of the study | Participants | Design | Programme | Key theme | Limitation |
|---|---|---|---|---|---|---|
| Blegen et al, 2015 USA | To describe newly licensed nurses' preceptorship and effects on competency and retention | Newly licensed nurses n=1375 from 82 hospitals | Longitudinal study (randomised controlled trial) | Preceptorship programme |
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| Hussein et al, 2018 Australia | To examine newly graduated nurses' perceptions of CSP and the practice environment, and how these influenced retention | NGNs n=109 participated, n=87 completed follow-up survey | Prospective observational study (no control group) | CSP |
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| Mather et al, 2015 Australia | To investigate the level of confidence clinical supervisors have concerning specific component of supporting students learning in the workplace | Clinical supervisors n=60 | Mixed method study (cohort without control group) | CSP |
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| Nielsen et al, 2016 USA | To gain insight into the new assessment process of clinical judgement | Staff nurse preceptors n=7 | Qualitative study | PP |
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| Puffett and Perkins, 2017 UK | To investigate what influences palliative care nurses in their choices to engage in or decline CSP | Staff nurses and healthcare assistants n=10 | Qualitative study | CSP |
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| Teferra and Mengistu, 2017 Ethiopia | To assess the knowledge and attitude of nurse educators towards preceptorship | Nurse educators n=117 | Cross-sectional study (cohort without a control group) | PP |
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CSP=clinical supervision programme; HPS=high preceptor support; LPS=low preceptor support; NGNs=newly graduated nurses; PP=preceptorship programme
Literature appraisal
Three different critical appraisal skill programme (CASP) checklists were used to assess the studies using a scoring system to grade the each study's quality. A higher score reflects the quality of the study, but that is subject to the variation of CASP elements which are not equal in number. CASP is considered as a gold standard for quality and validity appraisal for research studies (CASP, 2018). Therefore, three studies—Mather et al (2015), Teferra and Mengistu (2017) and Hussein et al (2019)— were appraised with CASP for cohort study and their scores were 22, 23 and 23 respectively (out of a possible score of 24). Two studies—Nielsen et al (2016), and Puffett and Perkins (2017)—were appraised with CASP for qualitative studies, and their scores were 20 and 20 respectively (out of a possible score of 20). The study by Blegen et al (2015) was appraised with CASP for randomised controlled trials, and the score was 19 (out of 22).
Data analysis
The data analysis process followed the thematic analysis steps when analysing and interpreting the study results. First, themes from the studies were identified and grouped into similar themes. Then the themes were named and renamed to form new emerging themes (Aveyard et al, 2016). As a result, several themes were identified as set out in Table 2. Seven main themes emerged, as discussed in the following sub-sections.
Increase satisfaction, gain competence and feel more confident
Increased job satisfaction and confidence to practise were reported in both PPs and CSPs in all selected studies. Similar to a previously reported study by Bifarin and Stonehouse (2017), Hussein et al (2019) found an increase in satisfaction of NQNs taking part in CSPs. Hussein et al (2019) examined NQNs' perceptions and intention to stay in clinical areas. They used the validated 26-item Manchester Clinical Supervision Scale (MCSS) (Winstanley and White, 2014) to predict NQNs' intention to stay in the current ward and used the practice environment scale-Australia (PES-AUS) to assess nurses' satisfaction with their clinical practice environment. The study found satisfaction with clinical supervision (MCSS mean score: 73 (interquartile range (IQR): 65-79)), and satisfaction with practice environment (PES-AUS mean score 111 (IQR: 99 – 120)). However, a small number of participants recruited from a single site may have limited the generalisability to other settings (Ajetunmobi, 2002). Similarly, Blegen et al (2015) reported an increase in preceptors' satisfaction with PPs, when they receive a reduced workload, and are precepting a small number of preceptees. Blegen et al's (2015) report is consistent with the previous study that having a preceptor with protected time increases preceptees' satisfaction (Omansky, 2010).
In terms of confidence, Nielson et al (2016) found two different groups of NQNs. One group showed low confidence, and the other group showed over-confidence (due to recently having graduated and therefore still having current theoretical knowledge). Puffett and Perkins (2017) advocated reflective learning for preceptees to gain competence and to feel more confident at the end of the programme.
In terms of competence, Blegen et al (2015) reported an increase in participants' competency levels. Self-rating competency of 1375 NQNs and preceptors showed a significant improvement in competencies in two areas—patient-centred care (P<0.054) and teamwork/communication (P<0.05). However, the attrition during the study period and no follow-up for drop-out participants may present bias and validity issues (Ajetunmobi, 2002).
Competencies of preceptors and supervisors
Studies by Teferra and Mengistu (2017) and Mather et al (2015) discussed the competencies required to be a preceptor and supervisor. Teferra and Mengistu (2017) carried out a cross-sectional study to assess the knowledge and attitude of the preceptors in PPs. Seventeen teaching institutions were randomly selected using a lottery method; from that, a total of 117 educators were identified and completed the research questionnaire. The study showed that 82.6% (n=90) claimed to be familiar with PP; but only 43.1% (n=47) were found to have adequate knowledge of nursing and PP. However, the sample size was small, which may limit the generalisability of these findings to other settings (Ajetunmobi, 2002).
Furthermore, Mather et al (2015) investigated the level of confidence of clinical supervisors concerning the specific components for supporting participants' learning in the workplace using a mixed-method study. A total of 60 participants completed a pre-workshop survey. The study found that all clinical supervisors need to have competencies within the clinical practice area and to be a role model and a source of information for supervisees. However, self-selection to attend workshops might have introduced bias to the study recruitment process (Ajetunmobi, 2002).
The point that Teferra and Mengistu (2017) and Mather et al (2015) made is that it requires knowledge, experience and proper training for one to assume the role of preceptor and supervisor. This point is also highlighted by Taylor et al (2019) that supervisors require formal training to gain competence before assuming the role.
Framework or model required
Nielsen et al (2016) carried out a qualitative study to gain insight into a new assessment process of clinical judgment in PPs. Seven volunteers took part in the study using a semi-structured interview. Thematic analysis showed three themes: the need for a framework, using a framework to foster clinical judgement, and evaluating competence. The participants identified that a framework for clinical judgement would provide an objective means for evaluating NQNs' clinical judgement competency. However, self-selected participants might have caused bias in the data collection process (Ajetunmobi, 2002).
In CSPs, Mather et al (2015), Nielsen et al (2016) and Puffett and Perkins (2017) discussed the need for a framework or model of reflection to assist the NQNs' learning experiences. Mather et al (2015) discussed the requirement for a clinical reasoning framework to improve the effectiveness of the CSP curriculum.
This framework consists of a series of ‘clinical reasoning cycles’. The cycle begins with the patient's situation, collecting the information, processing the information, identifying problems, establishing goals, taking action, evaluating outcomes, and reflecting on the process (Levett-Jones et al, 2012). Puffett and Perkins (2017) emphasised the need for a reflective model to support the participants to learn but was focused on Gibbs' (1988) five-cycles reflective model (description, feelings, evaluation, analysis, conclusion and action plan). The clinical reasoning model in Mather et al (2015) and the reflective cycles in Puffett and Perkins (2017) are both frameworks to help the participants to identify problems in practice, assess the problem, plan an action, evaluate the outcome and reflect on the process (Mather et al, 2015; Puffett and Perkins, 2017).
The challenge to the programmes
Teferra and Mengistu (2017) and Hussein et al (2019) highlighted challenges faced by the participants taking part in the programmes. In CSPs, Hussein et al (2019) highlighted the challenges for supervisors (who are also a regular nursing staff on the ward), which were associated with high admission rates, patients' acuity and the complexity of patients' conditions that required concentration, full attention and time. Consequently, supervisors spent less time with their supervisees. These challenges are similar to the findings of a previous study on CSPs by McCarron et al (2018), which highlighted that the lack of time to facilitate supervisees was the main challenge to CSPs. On the other hand, the challenges to the supervisees were associated with family-work conflicts and their new full-time role (Hussein et al, 2019), which affected their satisfaction with the practice environment. Teferra and Mengistu (2017) found that the lack of funding and incentives for preceptors frequently appeared in participants' responses. Also, the shortage of preceptors and a lack of training was identified as a challenge to the PPs, which is consistent with current published research by Taylor et al (2019). Taylor et al (2019) highlighted the lack of training for preceptors as the main weakness of the programme in many organisations.
Intention to stay and staff retention
Blegen et al (2015), Teferra and Mengistu (2017) and Hussein et al (2019) reported on the nurses' intention to stay in their current clinical practice after the training period. Blegen et al (2015) kept a record of NQNs hired and showed 86% (n=596 out of a total of 693) of NQNs were retained from high preceptor support (HPS) hospitals and 80% (n=545 out of a total of 682) from low preceptor support (LPS) hospitals. HPS hospitals are hospitals that provided full support for both preceptees and preceptors. For example, preceptees frequently worked with the preceptor, had different preceptors daily, had one-to-one support and shared workloads, and preceptors benefited from having a reduced workload, a smaller number of preceptees, and the opportunity to frequently work with preceptees. LPS hospitals provided less support than HPS hospitals (Blegen et al, 2015).
Similarly, Teferra and Mengistu (2017) claimed a 45% retention rate among NQNs at the end of PP. However, the retention rate was based on preceptors' responses to the research questionnaire, which may weaken the evidence of the claim (Ajetunmobi, 2002).
Overall, the intention to stay in the current job was associated with the support that participants receive from the management (Blegen et al, 2015), and the increased satisfaction with the job (Blegen et al, 2015; Teferra and Mengistu, 2017; Hussein et al, 2019). These are consistent with the study findings of McCarron et al (2018) and Taylor et al (2019) that increased satisfaction enhances the intention to stay, which ultimately improves nurse retention.
Voluntary withdrawal from the nursing profession
Blegen et al (2015) and Hussein et al (2019) reported NQNs' intention to withdraw at the end of the programmes. Blegen et al (2015) reported that a small percentage of NQNs from HPS and LPS hospitals voluntarily chose to withdraw at the end of PP, 14% and 19% respectively. Similarly, Hussein et al (2019) reported that a small number of NQNs had the intention to leave after the CSP programme. The reasons for withdrawal were dissatisfaction with the clinical environment, burnout and low confidence because of poor preparation during the CSP period. These findings were consistent with previous studies on CSP, which argued that nurses were leaving the nursing profession because of the absence of a sufficient support system (Zhang et al, 2014; Bifarin and Stonehouse, 2017).
Further support for development
Blegen et al (2015), Nielsen et al (2016), Puffett and Perkins (2017), Teferra and Mengistu (2017) and Hussein et al (2019) reported that further support was required from hospital management for developing the programmes. Blegen et al (2015) recommended that hospital management should provide protected time exclusively for preceptors in order to guide and evaluate their preceptees and share workloads with preceptees to promote independence. Most importantly they recommended that the preceptors should have fewer preceptees. Similarly, Nielsen et al (2016) recommended introducing protected time for preceptors to build preceptees' confidence and develop a professional relationship. To build this relationship, preceptors need to have reduced workloads in order to focus on helping preceptees to develop clinical skills and judgement (Nielsen et al, 2016; Teferra and Mengistu, 2017).
In the CSP programme, Puffett and Perkins (2017) emphasised the importance of informal team support. Their qualitative study investigated what influences palliative care nurses to engage in CSP. Convenience sampling was used to recruit 10 participants. The study found that ‘informal team support’ provided the opportunity for staff to discuss issues raised during CSP sessions in a friendly supportive environment. In addition, Hussein et al (2019) recommended a well-structured clinical setting orientation to support a transition to safe practice.
Limitations
Several limitations of the current literature review need to be acknowledged. First, unpublished literature was excluded from the data collection, which could have affected the findings. Second, this review included studies involving preceptors and supervisors, with half the studies concentrating on these staff members rather than NQNs, which may have limited the representation of NQN views in this literature research. However, including preceptors and supervisors in the review will paint a complete picture of the whole process of the training programmes. Finally, considering the geographical areas where these studies took place, the programmes may have been structured differently, potentially affecting the reliability of the evidence in this review.
Conclusion and recommendations
This literature review aimed to determine the importance of PPs and CSPs in retaining NQNs in their clinical placement. One of the more significant findings to emerge is that PPs and CSPs increased NQNs' confidence, competence and satisfaction at the end of the training programme. NQNs who showed satisfaction with the programme tended to choose to stay in their current clinical practice. Therefore, this literature review concludes that PPs and CSPs support the retention of nurses. However, due to potential bias in participant recruitment within the selected studies and the small sample sizes, caution must be applied when interpreting these results.
The authors recommend that both PPs and CSPs should be taken into consideration when designing a transition programme for NQNs. It is vital to provide ‘protected time’ for preceptors and supervisors to concentrate on guiding and training their preceptees and supervisees, and so should have a reduced workload during this time. It is also vital to create an ‘informal support group’ to share experiences and discuss the issues that arise from the programmes.