Associations Between the COVID-19 Pandemic and New Nurses’ Transition to Practice Outcomes: A Multi-site, Longitudinal Study

Bultas M.W.
L’Ecuyer K.M.

A longitudinal view of perceptions of entering nursing practice during the COVID-19 pandemic.

;

Crismon D.
Mansfield K.J.
Hiatt S.O.
Christensen S.S.
Cloyes K.G.

COVID-19 pandemic impact on experiences and perceptions of nurse graduates.

;

National Council of State Boards of Nursing, 2023

Smith S.M.
Buckner M.
Jessee M.A.
Robbins V.
Horst T.
Ivory C.H.

Impact of COVID-19 on new graduate nurses’ transition to practice: Loss or gain?.

), including close to 400,000 new nurses who passed the nursing licensing examination and became eligible to transition to practice (TTP) from nursing schools in the midst of the pandemic (

National Council of State Boards of Nursing. (2023). Exam statistics and publications. https://www.ncsbn.org/exams/exam-statistics-and-publications.page

Google Scholar

). During the pandemic, new nurses who were transitioning reported experiencing changes in their clinical and academic preparation resulting from reduced clinical site experiences and the quick switch from in-person to online learning (

Alsalamah Y.S.
Al Hosis K.
Al Harbi A.
Itani M.S.
El Tassi A.
Fawaz M.

Student to nurse transition and the nurse residency program: A qualitative study of new graduate perceptions.

;

Bultas M.W.
L’Ecuyer K.M.

A longitudinal view of perceptions of entering nursing practice during the COVID-19 pandemic.

;

Powers K.
Pate K.
Montegrico J.
Pagel J.

Faculty perceptions of the impact of the COVID-19 pandemic on new graduate nurses’ transition to practice: A qualitative study.

;

Ulmen B.F.
Witte C.E.
Speckhard S.T.
Fenske C.L.

Transition to practice: The use of virtual clinical replacement during the COVID-19 pandemic and its impact on new graduate nurse readiness.

). Furthermore, the pandemic caused interruptions to many hospitals’ TTP programs, which negatively impacted new nurses (

Crismon D.
Mansfield K.J.
Hiatt S.O.
Christensen S.S.
Cloyes K.G.

COVID-19 pandemic impact on experiences and perceptions of nurse graduates.

;

Bultas M.W.
L’Ecuyer K.M.

A longitudinal view of perceptions of entering nursing practice during the COVID-19 pandemic.

;

Smith S.M.
Buckner M.
Jessee M.A.
Robbins V.
Horst T.
Ivory C.H.

Impact of COVID-19 on new graduate nurses’ transition to practice: Loss or gain?.

). Although the existing research provides valuable insights into the impact of the COVID-19 pandemic on TTP for new nurses, it is limited to single sites and small samples (

Alsalamah Y.S.
Al Hosis K.
Al Harbi A.
Itani M.S.
El Tassi A.
Fawaz M.

Student to nurse transition and the nurse residency program: A qualitative study of new graduate perceptions.

;

Bultas M.W.
L’Ecuyer K.M.

A longitudinal view of perceptions of entering nursing practice during the COVID-19 pandemic.

;

Crismon D.
Mansfield K.J.
Hiatt S.O.
Christensen S.S.
Cloyes K.G.

COVID-19 pandemic impact on experiences and perceptions of nurse graduates.

;

Healy A.
Luca W.
Gallagher K.
Angelia A.J.
Book K.A.
Smith B.A.
Renkema A.
Kempf S.G.
Giordano N.A.
Polomano R.
Mastro K.A.

An evaluation of traditional versus virtual nurse residency programs on new graduate nurses’ perceptions of preparedness to provide safe patient care.

;

Powers K.
Pate K.
Montegrico J.
Pagel J.

Faculty perceptions of the impact of the COVID-19 pandemic on new graduate nurses’ transition to practice: A qualitative study.

;

Smith S.M.
Buckner M.
Jessee M.A.
Robbins V.
Horst T.
Ivory C.H.

Impact of COVID-19 on new graduate nurses’ transition to practice: Loss or gain?.

). The purpose of the present study was to expand the knowledge base on the topic by examining the differences across several standardized TTP measures in multiple cohorts of new nurses across 13 hospitals in Southeast Texas who participated in the Vizient/AACN (American Association of Colleges of Nursing) Nurse Residency Program (NRP) before and during the pandemic. The results of the study point to specific TTP outcomes for nurses participating in a standardized TTP program that were impacted by the COVID-19 pandemic that nurse educators and clinical leaders should prioritize for improvement to ensure positive outcomes for new nurses and their patients.

Literature Review

Upon graduation from nursing school, new nurses must transition the knowledge and skills they have learned in school into actual practice. This period, known as TTP, has been extensively studied in research conducted prior to the pandemic (

Chappell and Richards, 2015

Aldosari N.
Pryjmachuk S.
Cooke H.

Newly qualified nurses’ transition from learning to doing: A scoping review.

;

Chappell K.B.
Richards K.C.

New graduate nurses, new graduate nurse transition programs, and clinical leadership skill: A systematic review.

;

Dwyer and Hunter Revell, 2016

Dwyer P.A.
Hunter Revell S.M.

Multilevel influences on new graduate nurse transition: A literature review.

;

Goode et al., 2018

Goode C.J.
Glassman K.S.
Reid Pointe P.
Krugman M.
Peterman T.

Requiring a nurse residency for newly licensed registered nurses.

;

Mellor et al., 2017

Mellor P.
Gregoric C.
Atkinson L.M.
Greenhill J.A.

A critical review of transition to practice programs: Applying a standard model of evaluation.

;

Tyndall et al., 2018

Tyndall D.E.
Firnhaber G.C.
Scott E.S.

The impact of new graduate nurse transition programs on competency development and patient safety: An integrative review.

;

Warren et al., 2018

Warren J.I.
Perkins S.
Greene M.A.

Advancing new graduate education through implementation of statewide, standardized nurse residency programs.

). Additionally, research on the impact of the COVID-19 pandemic on TTP is now emerging (

Alsalamah Y.S.
Al Hosis K.
Al Harbi A.
Itani M.S.
El Tassi A.
Fawaz M.

Student to nurse transition and the nurse residency program: A qualitative study of new graduate perceptions.

;

Bultas M.W.
L’Ecuyer K.M.

A longitudinal view of perceptions of entering nursing practice during the COVID-19 pandemic.

;

Crismon D.
Mansfield K.J.
Hiatt S.O.
Christensen S.S.
Cloyes K.G.

COVID-19 pandemic impact on experiences and perceptions of nurse graduates.

;

Healy A.
Luca W.
Gallagher K.
Angelia A.J.
Book K.A.
Smith B.A.
Renkema A.
Kempf S.G.
Giordano N.A.
Polomano R.
Mastro K.A.

An evaluation of traditional versus virtual nurse residency programs on new graduate nurses’ perceptions of preparedness to provide safe patient care.

;

Powers K.
Pate K.
Montegrico J.
Pagel J.

Faculty perceptions of the impact of the COVID-19 pandemic on new graduate nurses’ transition to practice: A qualitative study.

;

Smith S.M.
Buckner M.
Jessee M.A.
Robbins V.
Horst T.
Ivory C.H.

Impact of COVID-19 on new graduate nurses’ transition to practice: Loss or gain?.

;

Ulmen B.F.
Witte C.E.
Speckhard S.T.
Fenske C.L.

Transition to practice: The use of virtual clinical replacement during the COVID-19 pandemic and its impact on new graduate nurse readiness.

).

Even before the pandemic, many new nurses reported struggling to successfully transition from a student to a nurse (

Aldosari N.
Pryjmachuk S.
Cooke H.

Newly qualified nurses’ transition from learning to doing: A scoping review.

;

Bultas M.W.
L’Ecuyer K.M.

A longitudinal view of perceptions of entering nursing practice during the COVID-19 pandemic.

;

Hallaran et al., 2022

Hallaran A.J.
Edge D.S.
Almost J.
Tregunno D.

New nurses’ perceptions on transition to practice: A thematic analysis.

;

Russell K.
Juliff D.

Graduate nurse transition programs pivotal point of participants’ practice readiness questioned during the COVID-19 pandemic crisis: A scoping review.

;

Smith S.M.
Buckner M.
Jessee M.A.
Robbins V.
Horst T.
Ivory C.H.

Impact of COVID-19 on new graduate nurses’ transition to practice: Loss or gain?.

;

Ulupinar S.
Aydogan Y.

New graduate nurses’ satisfaction, adaptation and intention to leave in their first year: A descriptive study.

). New nurses felt unprepared for practice, lacked confidence in their skills and care coordination abilities, experienced heavier workloads than expected, and had insufficient communication and professional skills (

Hallaran et al., 2022

Hallaran A.J.
Edge D.S.
Almost J.
Tregunno D.

New nurses’ perceptions on transition to practice: A thematic analysis.

;

Ulupinar S.
Aydogan Y.

New graduate nurses’ satisfaction, adaptation and intention to leave in their first year: A descriptive study.

). Feelings of being overwhelmed led new nurses to lose confidence or leave their jobs (

Aldosari N.
Pryjmachuk S.
Cooke H.

Newly qualified nurses’ transition from learning to doing: A scoping review.

;

Doughty et al., 2018

Doughty L.
McKillop A.
Dixon R.
Sinnema C.

Educating new graduate nurses in their first year of practice: The perspective and experiences of the new graduate nurses and the director of nursing.

;

Ulupinar S.
Aydogan Y.

New graduate nurses’ satisfaction, adaptation and intention to leave in their first year: A descriptive study.

), with 50.9% of new graduate nurses reporting that they were planning to leave their employer and 42.5% reporting that they were considering leaving nursing altogether in the years prior to the pandemic (

Ulupinar S.
Aydogan Y.

New graduate nurses’ satisfaction, adaptation and intention to leave in their first year: A descriptive study.

).

To help close the education-practice gaps, many hospitals utilize TTP programs or NRPs for nurses’ first year of employment (

Aldosari N.
Pryjmachuk S.
Cooke H.

Newly qualified nurses’ transition from learning to doing: A scoping review.

;

Bultas M.W.
L’Ecuyer K.M.

A longitudinal view of perceptions of entering nursing practice during the COVID-19 pandemic.

; NCSBN, n.d.;

Russell K.
Juliff D.

Graduate nurse transition programs pivotal point of participants’ practice readiness questioned during the COVID-19 pandemic crisis: A scoping review.

). Research prior to the COVID-19 pandemic showed that TTP programs help transition new nurses into practice by providing support to increase new nurses’ knowledge, skills, and abilities (

Russell K.
Juliff D.

Graduate nurse transition programs pivotal point of participants’ practice readiness questioned during the COVID-19 pandemic crisis: A scoping review.

). Several authors attributed an overall improvement in new nurses’ competence and confidence to participation in TTP programs (

Aldosari N.
Pryjmachuk S.
Cooke H.

Newly qualified nurses’ transition from learning to doing: A scoping review.

;

Russell K.
Juliff D.

Graduate nurse transition programs pivotal point of participants’ practice readiness questioned during the COVID-19 pandemic crisis: A scoping review.

;

Van Camp and Chappy, 2017

Ulupinar S.
Aydogan Y.

New graduate nurses’ satisfaction, adaptation and intention to leave in their first year: A descriptive study.

;

Van Camp J.
Chappy S.

The effectiveness of nurse residency programs on retention: A systematic review.

). Similarly,

Spector et al., 2015

Spector N.
Blegen M.
Silvestre J.
Ulrich B.
Fogg L.
Alexander M.

Transition to practice study in hospital settings.

found that hospitals with standardized TTP programs that focus on quality and safety competencies, clinical reasoning, reflection, and specialty knowledge in an area of practice were associated with better TTP outcomes.

A handful of studies have examined the impact of the COVID-19 pandemic on TTP. The pandemic caused many nursing students to lose hospital-based clinical experiences and hands-on knowledge application opportunities (

Crismon D.
Mansfield K.J.
Hiatt S.O.
Christensen S.S.
Cloyes K.G.

COVID-19 pandemic impact on experiences and perceptions of nurse graduates.

;

Powers K.
Pate K.
Montegrico J.
Pagel J.

Faculty perceptions of the impact of the COVID-19 pandemic on new graduate nurses’ transition to practice: A qualitative study.

;

Ulmen B.F.
Witte C.E.
Speckhard S.T.
Fenske C.L.

Transition to practice: The use of virtual clinical replacement during the COVID-19 pandemic and its impact on new graduate nurse readiness.

). One organization found that 67.5% of new nurses had fewer clinical practice experiences that their pre-pandemic counterparts, resulting in the nurses feeling overwhelmed, concerned for lack of efficiency, afraid of making mistakes after their orientation, and deficient in hands-on skills resulting from a lack of significant practice repetition (

Smith S.M.
Buckner M.
Jessee M.A.
Robbins V.
Horst T.
Ivory C.H.

Impact of COVID-19 on new graduate nurses’ transition to practice: Loss or gain?.

). During the pandemic, new nurses also experienced altered orientation plans, rapid changes to hospital policies, and increased workloads, which exacerbated new nurses’ stress, workload, and the discrepancy between their expectations and reality. A longitudinal study on new nurses’ TTP experience during the pandemic revealed that 96% of new nurses rated their experience as negative and reported an inability to form effective peer relationships, lowered confidence in their preparation and abilities, and increased concern for personal health and safety (

Bultas M.W.
L’Ecuyer K.M.

A longitudinal view of perceptions of entering nursing practice during the COVID-19 pandemic.

). In a survey of nurse faculty about their perceptions of the impact of the COVID-19 pandemic on new nurses’ TTP, faculty were most concerned about the loss of hands-on learning in clinical settings and emphasized the need to counteract the loss of clinical experiences in school through enhanced TTP programs and mentorship on the job (

Powers K.
Pate K.
Montegrico J.
Pagel J.

Faculty perceptions of the impact of the COVID-19 pandemic on new graduate nurses’ transition to practice: A qualitative study.

).

Two published studies examined the outcomes of new nurses who participated in standardized TTP programs.

Healy A.
Luca W.
Gallagher K.
Angelia A.J.
Book K.A.
Smith B.A.
Renkema A.
Kempf S.G.
Giordano N.A.
Polomano R.
Mastro K.A.

An evaluation of traditional versus virtual nurse residency programs on new graduate nurses’ perceptions of preparedness to provide safe patient care.

conducted a single-site study of 99 new nurses in the United States comparing a pre-pandemic cohort of new nurses participating in an in-person Vizient/AACN NRP to a pandemic cohort of new nurses who participated in a virtual Vizient/AACN NRP. The authors reported no differences across scores from the Casey–Fink Graduate Nurse Experience Survey that measured new nurses’ perceptions of support, patient safety, stress, communication/leadership, professional satisfaction, and job satisfaction, and the Vizient/AACN NRP Nurse Resident Progression Survey that measured advocacy, collaboration, leadership, and commitment. In a study of 29 new nurses from Saudi Arabia who were in a standardized NRP,

Alsalamah Y.S.
Al Hosis K.
Al Harbi A.
Itani M.S.
El Tassi A.
Fawaz M.

Student to nurse transition and the nurse residency program: A qualitative study of new graduate perceptions.

found that new nurses reported challenges with TTP but believed that the NRP offered enhanced learning and peer support.

Research Questions

Our study sought to build on the existing research by examining the associations between several self-reported TTP outcome measures and the COVID-19 pandemic in nurses across multiple hospitals who participated in a standardized NRP. Using robust methods and a large sample size, we sought answers to the following research questions:

1.
What are the differences in TTP outcome measures of new nurses who transitioned to practice in 2017–2019 (pre–COVID-19 cohort) compared with those who transitioned in 2020 and 2021 (COVID-19 cohort) at baseline?
2.
What are the differences in TTP outcome measures of new nurses transitioning to practice in in the pre–COVID-19 cohort compared with the COVID-19 cohort at 12 months?
3.
What are the associations between changes from baseline to 12 months in TTP outcome measures and COVID-19 exposure adjusting for differences in demographic variables such as gender, ethnicity, degree, and grade point average (GPA)?

The TTP period offers a unique opportunity for employers to assess gaps in essential competencies and implement interventions to close any gaps that can negatively affect organizational performance (

Aldosari N.
Pryjmachuk S.
Cooke H.

Newly qualified nurses’ transition from learning to doing: A scoping review.

;

Russell K.
Juliff D.

Graduate nurse transition programs pivotal point of participants’ practice readiness questioned during the COVID-19 pandemic crisis: A scoping review.

). Thus, the results of our study could provide information on competency gaps specific to the COVID-19 pandemic according to new nurses’ perspectives.

Methods

Study Design

We used a correlational longitudinal design to analyze self-reported survey data previously collected and stored in the Vizient/AACN NRP database (

Vizient, 2023

Vizient. (2023). Vizient/AACN Nurse Residency Program Survey (2017-2021). http://www.vizientinc.com

Google Scholar

) using two Vizient/AACN NRP survey instruments: the Casey-Fink Graduate Nurse Experience Survey (

Casey and Fink, 2015

Casey, K., & Fink, R. (2015). Casey-Fink Graduate Nurse Experience Survey reliability and validity issues. https://www.uchealth.org/wp-content/uploads/2016/10/PROF-CF-reliability-and-validity-2014.pdf

Google Scholar

;

Fink et al., 2008

Fink R.
Krugman M.
Casey K.
Goode C.

The graduate nurse experience: Qualitative residency program outcomes.

) and the Nurse Resident Progression Survey (

Vizient, (n.d)

Vizient

Vizient/AACN Nurse Residency Program.

Google Scholar

) at baseline and 12 months from nurses transitioning to practice from 2017 to 2021 across 13 hospitals in a single health system in Southeast Texas. The data collection points (baseline and 12 months) were set by Vizient/AACN NRP to correspond with the beginning and end of the 1-year residency program. The study received exempt status from the UTHealth Houston Committee for the Protection of Human Subjects because the data were anonymized at the participant and institutional levels.

Sample and Setting

The sample was comprised of new nurses from 13 hospitals in a large not-for-profit health system in Southeast Texas who participated in the health system’s Vizient/AACN NRP. The health system’s first formal NRP program started in January 2010 at the health system’s flagship academic hospital utilizing the UHC/AACN NRP framework, which is now known as the Vizient/AACN NRP. In 2014, the program expanded to 13 hospitals within the health system using the 12-month NRP framework (Y. Short, personal communication, October 19, 2022). Hospital and nursing orientation take place at the campus level with nurse residents meeting regularly throughout the year to interact with peers and grow their professional skill set. Due to the program’s large size, new nurses are divided into 2 to 3 groups that meet monthly at residency seminars. The seminars are designed utilizing the Vizient/AACN NRP curriculum and focus on topics such as the role of the professional nurse, quality outcomes, and leadership at the bedside. Nurse residents also network with peers from throughout the system through specialty core curriculum classes. These classes provide foundational education and training in the following nursing specialties: inpatient acute care, critical care, emergency care, perinatal services, perioperative services, pediatrics, and neonatal intensive care. Nurse residents are required to attend classes and to complete an evidence-based practice project. Experienced nurses at both the system and facility level provide oversight and assistance with these projects as needed. Nurse residents present their projects at the completion of the program (

Vizient, (n.d)

Vizient

Vizient/AACN Nurse Residency Program.

Google Scholar

). While the program content stayed the same during the pandemic, the program delivery was shifted from an in-person to a web-based environment.

Beginning in fiscal year 2017, three groups of new nurses were onboarded per year. On average, the health system accepts approximately 526 nurse residents into the program annually with a 1-year retention rate of 96%. The new nurses in the study sample were defined as those who had less than 12 months of work experience (Y. Short, personal communication, October 19, 2022).

Data Collection

The health system collected data regarding new nurses from its 13 hospitals in collaboration with Vizient. New nurses who participated in the Vizient/AACN NRP responded to surveys via an electronic portal. The responses to the surveys were submitted electronically into Vizient and automatically entered into their database. A data coordinator from Vizient then prepared and shared data from the Vizient database with the research team for analyses. The data contained no personal or individual hospital identifying information. All participants in the Vizient/AACN NRP surveys completed a consent form acknowledging that the data from the surveys may be used for research purposes. The nurses were not mandated to complete the anonymous surveys, and the anonymous data were only reported in aggregate. Nurses were not required to respond to all survey items.

Outcome Measures

Outcome measures were selected from the pre-existing Vizient/AACN NRP surveys to answer the proposed research questions. The predictor measures included time (baseline and 12 months) and the COVID-19 pandemic status, measured as a dichotomous variable with “no exposure” for the control group of new nurses transitioning to practice in 2017, 2018, and 2019 and “positive exposure” for the cohorts of new nurses transitioning to practice in 2020 and 2021. The covariate measures included age, gender, ethnicity, nursing degree type, and GPA.

The outcome measures included the following scales from the Casey-Fink Graduate Nurse Experience Survey (

Casey and Fink, 2015

Casey, K., & Fink, R. (2015). Casey-Fink Graduate Nurse Experience Survey reliability and validity issues. https://www.uchealth.org/wp-content/uploads/2016/10/PROF-CF-reliability-and-validity-2014.pdf

Google Scholar

;

Fink et al., 2008

Fink R.
Krugman M.
Casey K.
Goode C.

The graduate nurse experience: Qualitative residency program outcomes.

;

Healy A.
Luca W.
Gallagher K.
Angelia A.J.
Book K.A.
Smith B.A.
Renkema A.
Kempf S.G.
Giordano N.A.
Polomano R.
Mastro K.A.

An evaluation of traditional versus virtual nurse residency programs on new graduate nurses’ perceptions of preparedness to provide safe patient care.

): support (9 items; e.g., “I feel supported by the nurses on my unit”), patient safety (5 items; e.g., “I feel I may harm the patient due to my lack of knowledge and experience”), overall stress (1 item: “I am experiencing stress in my personal life”), communication/leadership (6 items; e.g., “I feel comfortable communicating with patients and their families”), professional satisfaction (3 items; e.g., “I am satisfied with my chosen nursing specialty”), and job satisfaction (9 items; e.g., “Satisfaction with work responsibilities”). Outcome measures also included the following scales from the Nurse Resident Progression Survey that were used in prior research (

Healy A.
Luca W.
Gallagher K.
Angelia A.J.
Book K.A.
Smith B.A.
Renkema A.
Kempf S.G.
Giordano N.A.
Polomano R.
Mastro K.A.

An evaluation of traditional versus virtual nurse residency programs on new graduate nurses’ perceptions of preparedness to provide safe patient care.

): advocacy (18 items), collaboration (6 items), leadership (13 items), and commitment (14 items). Total scores were divided by the number of questions, resulting in a score that corresponded closely to the Likert scale used for the survey questions. Likert scale values ranged from 1 to 4, where 1 represented strong disagreement and 4 implied strong agreement. The exception was the job satisfaction scale, which had response options that ranged from 1 (representing very dissatisfied) to 5 (representing very satisfied).

Content validity was reported previously for both surveys (

Casey and Fink, 2015

Casey, K., & Fink, R. (2015). Casey-Fink Graduate Nurse Experience Survey reliability and validity issues. https://www.uchealth.org/wp-content/uploads/2016/10/PROF-CF-reliability-and-validity-2014.pdf

Google Scholar

;

Fink et al., 2008

Fink R.
Krugman M.
Casey K.
Goode C.

The graduate nurse experience: Qualitative residency program outcomes.

;

Healy A.
Luca W.
Gallagher K.
Angelia A.J.
Book K.A.
Smith B.A.
Renkema A.
Kempf S.G.
Giordano N.A.
Polomano R.
Mastro K.A.

An evaluation of traditional versus virtual nurse residency programs on new graduate nurses’ perceptions of preparedness to provide safe patient care.

). We conducted an internal consistency reliability analysis for the survey measures using baseline (0 months) data in the studied sample and found acceptable Cronbach alpha scores across all multi-item scales: support (.826), patient safety (.734), communication/leadership (.755), professional satisfaction (.768), job satisfaction (.849), collaboration (.727), leadership (.965), commitment (.926), and advocacy (.951).

Analysis

Baseline and 12-month characteristics were described as frequency (%) for categorical variables and as mean (SD) for continuous variables. Descriptive statistics were stratified by pre–COVID-19 and COVID-19 cohorts. Distributions of demographic variables were compared with two-sample t tests for age and chi-squared tests for gender, ethnicity, degree, and GPA. Propensity scores (

Blackford, 2009

Blackford J.U.

Propensity scores: method for matching on multiple variables in down syndrome research.

) were calculated from logistic regression in order to adjust for demographic differences in subsequent models. To minimize the impact of missing demographic data, propensity scoring models were investigated with and without variables that had large fractions of missing values (i.e., age, ethnicity, and GPA). Akaike information criteria (AIC) indicated that age and ethnicity were not necessary, but GPA was important to include in the model. Thus, the final scoring model included degree, GPA, and gender. The longitudinal analysis was carried out with linear mixed effects models (

Bates et al., 2015

Bates D.
Mächler M.
Bolker B.
Walker S.

Fitting linear mixed-effects models using lme4.

) for each scale score. Fixed effects included the interaction of time and COVID-19 exposure along with the propensity score. The presence of a significant interaction term indicated that improvement in a given scale’s mean score over 12 months was unequal in the study cohorts. Statistical analyses were done using R software version 4.0.3 or later (2020), and α = .05 was used for statistical inference. Post hoc power calculations were performed using G*Power 3.1 using Cohen’s method for repeated measures design, with α = .05 (

Faul et al., 2009

Faul F.
Erdfelder E.
Buchner A.
Lang A.-G.

Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses.

).

Results

Data were available for 2,673 new nurses from 13 hospitals who were enrolled in the TTP program; 1,475 of the nurses were enrolled in either 2017, 2018, or 2019 (before the COVID-19 pandemic) and 1,198 entered in 2020 (after March) or 2021 (after the COVID-19 pandemic began). Sample sizes and demographic characteristics of the sample are displayed in Table 1. Ethnicity distributions differed in the cohorts, with the COVID-19 cohort having fewer participants who self-identified as White and more who self-identified in each of the other ethnic groups compared with the pre–COVID-19 cohort. The cohorts also differed in education; there were more bachelor’s degree nurses with higher GPAs in the COVID-19 cohort. Age and gender compositions of the cohorts were similar before and during the COVID-19 pandemic.

Table 1Participant Demographics by Study Cohort

Characteristic	Pre–COVID-19 (N = 1,475)	COVID-19 (N = 1,198)	p Value ^a Welch two-sample t test; Pearson’s chi-squared test.
Age, y, M (SD)	27 (7)	27 (7)	.825
Unknown, n	672	240
Gender, n (%)			.427
Female	1,250 (85%)	1,028 (86%)
Male	223 (15%)	168 (14%)
Unknown, n	2	2
Ethnicity, n (%)			.038
White	554 (46%)	416 (40%)
Hispanic or Latino	242 (20%)	232 (22%)
Black or African-American	199 (17%)	184 (18%)
Asian	164 (14%)	169 (16%)
Other	34 (2.8%)	38 (3.7%)
Unknown, n	282	159
Degree Received, n (%)			<.001
BSN/BA/BS	970 (66%)	854 (72%)
Accelerated BSN	180 (12%)	151 (13%)
ADN	321 (22%)	189 (16%)
Unknown, n	4	4
GPA, n (%)			.017
<3.5	682 (58%)	634 (53%)
3.5	498 (42%)	564 (47%)
Unknown, n	295	0

Note. ADN = associate degree in nursing; BA = bachelor of arts; BS = bachelor of science; BSN = bachelor of science in nursing; GPA = grade point average. Unknown data were not included in percentage calculations.

a Welch two-sample t test; Pearson’s chi-squared test.

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Not all new nurses responded to the surveys at either baseline or 12 months; thus, the number of available responses in the dataset dictated the sample size. However, post hoc power calculations showed that the smallest survey response number in the dataset (N = 780 observed at 12 months for the COVID-19 cohort) was sufficient to provide at least 80% power to detect a small effect (η2 = 0.01) due to the interaction of time and the cohorts. When missing values were considered, the smallest count was N = 597 for the 12-month advocacy scale in the COVID-19 cohort, for which the power stayed above 79.9% to detect the small effect.

Descriptive statistics of the scale scores at baseline and 12 months and stratified by COVID-19 exposure are shown in Table 2. The results from linear mixed models are displayed in Table 3. The descriptive trends in TTP outcomes appear similar for nurses transitioning to practice before and during the COVID-19 pandemic. Overall, leadership/communication, leadership, and patient safety scores tended to be lower compared to advocacy and collaboration scores at baseline and 12 months in all cohorts, but each of these scales, with the exception of collaboration, had noted improvements from baseline to 12 months. Support, job satisfaction, professional satisfaction, and commitment showed a decrease from baseline to 12 months in all cohorts.

Table 2Transition to Practice Outcomes at Baseline and 12 Months by Study Cohort

Scale	Range	Pre–COVID-19, M (SD)		During COVID-19, M (SD)
Scale	Range	Baseline (N = 1,420)	12 Months (N = 1,137)	Baseline (N = 1,148)	12 Months (N = 780)
Casey-Fink Graduate Nurse Experience Survey
Support	1-4	3.45 (0.40)	3.37 (0.43)	3.46 (0.40)	3.39 (0.41)
Unknown, n		2	2	2	3
Patient safety	1-4	2.73 (0.47)	3.13 (0.48)	2.80 (0.44)	3.05 (0.51)
Unknown, n		2	2	2	3
Stress	1-4	2.35 (0.82)	2.36 (0.82)	2.34 (0.79)	2.41 (0.83)
Unknown, n		2	2	2	3
Communication/leadership	1-4	2.63 (0.43)	3.20 (0.41)	2.69 (0.45)	3.23 (0.42)
Unknown, n		2	2	2	3
Professional satisfaction	1-4	3.58 (0.47)	3.31 (0.54)	3.54 (0.46)	3.28 (0.55)
Unknown, n		2	2	2	3
Job satisfaction	1-5	3.94 (0.57)	3.69 (0.62)	3.95 (0.59)	3.67 (0.65)
Unknown, n		2	2	2	3
Nurse Resident Progression Survey
Advocacy	1-4	3.20 (0.46)	3.43 (0.42)	3.26 (0.45)	3.45 (0.41)
Unknown, n		634	309	501	183
Collaboration	1-4	3.33 (0.43)	3.31 (0.43)	3.33 (0.41)	3.31 (0.43)
Unknow, nn		24	33	19	18
Leadership	1-4	1.98 (0.57)	2.27 (0.51)	2.05 (0.57)	2.32 (0.55)
Unknown, n		24	33	19	18
Commitment	1-4	3.28 (0.40)	2.86 (0.49)	3.25 (0.42)	2.81 (0.50)
Unknown, n		24	33	19	18

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Table 3Differences in Transition to Practice Outcomes Between Study Cohorts From Baseline to 12 Months

Scale	β ^a Linear mixed models for each scale are summarized by the interaction term β, which represents the difference in improvement from baseline to 12 months in the COVID-19 cohort relative to the pre–COVID-19 cohort. For example, β of -0.05 represents the difference in negative improvement from baseline to 12 months in the COVID-19 cohort compared to the pre–COVID-19 cohort. The models are adjusted with propensity scores to control differences in distributions of demographic composition of the cohorts.	95% CI		p Value
Scale		Lower	Upper	p Value
Casey-Fink Graduate Nurse Experience Survey
Support	0.00	-0.04	0.04	.906
Patient safety	-0.15	-0.20	-0.11	<.001
Stress	0.04	-0.04	0.12	.361
Communication/leadership	-0.03	-0.07	0.01	.199
Professional satisfaction	-0.02	-0.07	0.03	.358
Job satisfaction	-0.05	-0.11	0.00	.054
Nurse Resident Progression Survey
Advocacy	-0.06	-0.12	-0.01	.021
Collaboration	-0.02	-0.06	0.03	.430
Leadership	0.00	-0.05	0.05	.971
Commitment	-0.05	-0.09	-0.01	.017

a Linear mixed models for each scale are summarized by the interaction term β, which represents the difference in improvement from baseline to 12 months in the COVID-19 cohort relative to the pre–COVID-19 cohort. For example, β of -0.05 represents the difference in negative improvement from baseline to 12 months in the COVID-19 cohort compared to the pre–COVID-19 cohort. The models are adjusted with propensity scores to control differences in distributions of demographic composition of the cohorts.

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Stress scores were stable from baseline to 12 months in the pre–COVID-19 cohort. The COVID-19 cohort reported a small increase in stress from baseline (M = 2.34; SD = 0.83) to 12 months (M = 2.41; SD = 0.83), but the difference in the score changes between the study cohorts was not statistically significant (p = .361). The advocacy score increased in both cohorts over 12 months, but the increase was smaller in the COVID-19 cohort (p = 0.21). The mean score of advocacy was almost the same at 12 months before (M = 3.43; SD = 0.42) and during (M = 3.45; SD = 0.41) COVID-19, while the initial value of the advocacy score was slightly higher in the cohorts during (M = 3.26; SD = 0.45) versus before (M = 3.20; SD = 0.46) COVID-19. Patient safety scores increased over 12 months in both groups, but the increase was smaller in the COVID-19 cohort (p < .001). Moreover, the mean patient safety score was higher initially during (M = 2.80; SD = 0.44) compared to before (M = 2.73; SD = 0.47) COVID-19 and lower at 12 months during (M = 3.05; SD = 0.51) compared to before (M = 3.13; SD = 0.48) COVID-19. Commitment scale scores decreased over 12 months in both groups, with a slightly larger decrease during COVID-19 (from M = 3.25; SD = 0.42 to M = 2.81; SD = 0.50) compared to pre–COVID-19 (from M = 3.28; SD = 0.40 to M = 2.86; SD = 0.49) (p = .017). Other scales did not show evidence of a change in their pattern over 12 months before and during the COVID-19 pandemic.

Discussion

The TTP from education settings is a stressful and challenging experience for new nurses (

Aldosari N.
Pryjmachuk S.
Cooke H.

Newly qualified nurses’ transition from learning to doing: A scoping review.

). It is also a critically important period for employers to assess education practice gaps and intervene for positive nurse and patient outcomes (

Tyndall et al., 2018

Tyndall D.E.
Firnhaber G.C.
Scott E.S.

The impact of new graduate nurse transition programs on competency development and patient safety: An integrative review.

). Research is emerging on the impact of the COVID-19 pandemic on new nurses’ TTP experiences (

Crismon D.
Mansfield K.J.
Hiatt S.O.
Christensen S.S.
Cloyes K.G.

COVID-19 pandemic impact on experiences and perceptions of nurse graduates.

;

Bultas M.W.
L’Ecuyer K.M.

A longitudinal view of perceptions of entering nursing practice during the COVID-19 pandemic.

;

Smith S.M.
Buckner M.
Jessee M.A.
Robbins V.
Horst T.
Ivory C.H.

Impact of COVID-19 on new graduate nurses’ transition to practice: Loss or gain?.

). Our study adds to this line of inquiry as the first study that compares TTP measures between the cohorts of new nurses who transitioned to practice before and during the COVID-19 pandemic and participated in a standardized TTP.

In terms of demographic differences, the new nurses entering practice during the COVID-19 pandemic were more diverse, had a higher overall GPA, and were more likely to have a bachelor’s degree, which could be attributed to the long-standing national agenda to increase diversity and the percentage of nurses entering practice with a bachelor’s degree. When adjusting for the demographic composition of the cohorts, differences were identified in the changes from baseline to 12 months in advocacy, patient safety, and commitment scores. The reported increase in the advocacy score from baseline to 12 months was greater in the pre–COVID-19 cohort compared to the COVID-19 cohort, although overall, the COVID-19 cohort had a higher overall baseline and 12-month advocacy score than the pre–COVID-19 cohort. Our finding of increased reported advocacy skills in the COVID-19 cohort is consistent with other reports of new nurses’ heightened awareness of the importance of advocating for the patients and themselves during a pandemic (

Bultas M.W.
L’Ecuyer K.M.

A longitudinal view of perceptions of entering nursing practice during the COVID-19 pandemic.

;

Crismon D.
Mansfield K.J.
Hiatt S.O.
Christensen S.S.
Cloyes K.G.

COVID-19 pandemic impact on experiences and perceptions of nurse graduates.

). Conversely, the patient safety score had a greater increase from baseline to 12 months in the pre–COVID-19 cohort and higher overall scores at baseline and 12 months. The reductions in patient safety align with findings in the literature related to reduced clinical site experiences and reduced in-classroom learning opportunities during the COVID-19 pandemic (

Bultas M.W.
L’Ecuyer K.M.

A longitudinal view of perceptions of entering nursing practice during the COVID-19 pandemic.

;

Ulmen B.F.
Witte C.E.
Speckhard S.T.
Fenske C.L.

Transition to practice: The use of virtual clinical replacement during the COVID-19 pandemic and its impact on new graduate nurse readiness.

). Commitment scores decreased from baseline to 12 months, with a greater decline reported in the COVID-19 cohort. The small but statistically significant reduction in commitment in the COVID-19 cohort in our study aligns with other studies that reported decreases in organizational commitment that were exacerbated during the pandemic along with increased burnout, stress, and sense of being overwhelmed (

Bultas M.W.
L’Ecuyer K.M.

A longitudinal view of perceptions of entering nursing practice during the COVID-19 pandemic.

;

Crismon D.
Mansfield K.J.
Hiatt S.O.
Christensen S.S.
Cloyes K.G.

COVID-19 pandemic impact on experiences and perceptions of nurse graduates.

). In addition, new nurses’ organizational commitment commonly decreases after 1 year, leading to high first-year turnover rates, even in organizations with TTP programs (

Ulupinar S.
Aydogan Y.

New graduate nurses’ satisfaction, adaptation and intention to leave in their first year: A descriptive study.

). It is important to note that although statistically significant, changes in the advocacy and commitment scores were smaller compared to the changes in the patient safety score, which was a concern for nurses’ TTP even before the COVID-19 pandemic (NCSBN, n.d.).

Although new nurses reported moderate levels of stress both before and during the pandemic, we were surprised to find that there were no differences in the overall stress between the pre–COVID-19 and COVID-19 cohorts. This finding is inconsistent with other research (

Bultas M.W.
L’Ecuyer K.M.

A longitudinal view of perceptions of entering nursing practice during the COVID-19 pandemic.

;

Crismon D.
Mansfield K.J.
Hiatt S.O.
Christensen S.S.
Cloyes K.G.

COVID-19 pandemic impact on experiences and perceptions of nurse graduates.

) and informal reports from the front lines. It is possible that the new nurses’ transitioning to practice during the pandemic did not have a pre-pandemic comparison experience—in other words, this was their only experience of transition, which was stressful, but not more so than the stress experienced by new nurses before the pandemic. Furthermore, the lack of differences in collaboration, leadership, and communication scores was also unexpected. However, it is possible that TTP programs in our study sites were able to adapt well to the changing environment of the pandemic to continue to successfully support new nurses’ TTP experiences.

In terms of key recommendations for regulation, education, and practice based on our and related findings (