Many countries are experiencing a shortage of nurses. In Korea, the aging population, increased demand for quality nursing care, and changes in the health care system, such as implementation of the reimbursement system according to the ratio of patients to nurses and comprehensive nursing care system, have led to increased demand for nurses. Accordingly, the Korean government has established and expanded the educational institutions for the training of nursing in an effort to increase the number of nurses. As a result, in 2021, the number of new graduate nurses increased by 183.4% compared to that in 2010 [1]. However, despite the increased number of nurses, the turnover rate of new graduate nurses with less than one year of employment increased to 44.5% in 2020 [2]. The high turnover rate of new graduate nurses is a global trend. New graduate nurses who graduate from university and start working as professional nurses have low independent work capacity and difficulties in interpersonal relationships. Therefore, they require support and mentoring for the first few months. Nurses who do not effectively acquire the skills and knowledge required for their tasks and fail to adapt to the organization eventually opt to change their jobs [3].
In recent years, the role of preceptors has become increasingly important in clinical practice to help new graduate nurses adapt to the new work environment, socialize, and improve work capacity [4]. Preceptors serve as educators who help new graduate nurses acquire knowledge and skills based on nursing theory. They act as role models for new graduate nurses and assist them in overcoming the shock and burden of transitioning to an unfamiliar work environment to ensure that they can eventually adapt to and remain with the organization [3, 5, 6, 7, 8]. In addition to showing desirable teaching behavior and providing practical technical education, preceptors must build a learning atmosphere, use appropriate teaching strategies, guide inter-professional communication, provide feedback and evaluation, and show concern and support to the nurses [6, 9, 10].
Effective preceptorship and preceptors' teaching behavior is a key influencing factor on the resilience [11] and organizational socialization [8, 12] of new graduate nurses and positively affects the retention of new graduate nurses in the organization [5, 6, 10]. Transitioning to a registered nurse role can leave new graduate nurses feeling stressed, and many have difficulty adjusting to the reality of caring for multiple patients with highly complex cases [13]. The challenges of transitioning impact the resilience of new graduate nurses [11]. Resilience is the ability to cope and adjust to challenges that can be daunting and overwhelming for new graduate nurses who lack personal skills or experiences [14]. Nurses with high resilience can overcome challenges and improve their skills as professional nurses. In contrast, individuals with low resilience cannot endure negative emotions caused by difficulties and excessive stress in clinical practice, which leads to their burnout and turnover [15]. Relationship with preceptor might contribute to resilience of new graduate nurses by improving positive and supportive professional relationships [11]. Resilience is a key factor in helping new graduate nurses achieve successful organizational socialization [16].
Preceptors are vital in helping new graduate nurses to bridge the gap between academia and practice, thus increasing their knowledge, socializing them to their role as a nurse, and assisting them to become a part of their unit's culture and team [8, 12]. Organizational socialization is the process of learning the work ethic, performance capacity, expected behaviors, and knowledge established within the organization that are necessary for organizational members [17]. For new graduate nurses, the initial period of employment is the most sensitive and crucial period affecting their successful adaptation as an organizational member. Therefore, new graduate nurses must enhance their resilience and organizational socialization during this period. Additionally, effective preceptors' teaching behavior during the initial period of employment is likely to positively affect the clinical performance of new graduate nurses [18] and assist them in becoming professionals through a successful long-term career in professional nursing [5, 6, 10]. This is consistent with the finding that nurse turnover increases when their relationship and communication with the preceptors are at their peak [19].
Several studies have shown that effective preceptorship positively affects the retention of new graduate nurses [3, 5, 10, 18]. However, few studies have comprehensively examined the effects of the various teaching behaviors of preceptors, which have recently been emphasized from the perspective of both preceptors and preceptees, on new graduate nurses' resilience, organizational socialization, and intention to stay, as well as the relationship between these variables. Therefore, this study aimed to investigate the effects of the teaching behavior of preceptors, who have the closest relationship with new graduate nurses, on the intention to stay of new graduate nurses through the mediating effects of resilience and organizational socialization. This study provides basic data for the effective human resource management of nurses with the aim of increasing the intention to stay and the development of professional nurses.
1. Study Design
This descriptive research aimed to investigate the mediating effects of resilience and organizational socialization among the effects of preceptors' teaching behavior on the intention to stay of new graduate nurses.
2. Participants
The participants of this study were new graduate nurses who obtained their nursing license, completed preceptor training, and worked at a single university hospital in C city for more than three months and less than 12 months were selected as study participants. All participants understood the study purpose and voluntarily consented to participate. The number of participants required in this study was calculated using the G*Power 3.1.9.2 program. The regression analysis test was conducted with 13 predictors, with a median effect size of 0.15, significance level of 0.05, and statistical power of 0.90. The minimum number of required participants was 162. Considering dropouts, a total of 200 questionnaires were distributed, and data from 167 retrieved questionnaires were analyzed.
3. Measurements
1) Preceptors' teaching behavior
The clinical teaching behavior inventory (CTBI), developed by Lee-Hsieh et al. [10] and translated into Korean by Jung et al. [6], with tested reliability and validity was used. The tool comprised 22 items in six sub-factors: “committing to teaching” (3 items), “building a learning atmosphere” (5 items), “using appropriate teaching strategies” (5 items), “guiding inter-professional communication” (3 items), “providing feedback and evaluation” (3 items), and “showing concern and support” (3 items). Each item was evaluated on a 5-point Likert scale from “strongly disagree” (1 point) to “strongly agree” (5 points), and a higher score indicated more positive teaching behavior as a preceptor. The Cronbach's α of the tool used in this study was .97.
2) Resilience
The resilience of new graduate nurses was measured using a tool developed by Park and Park [20]. The tool comprises 30 items in five sub-factors: dispositional pattern (5 items), relational pattern (4 items), situational pattern (10 items), philosophical pattern (6 items), and professional pattern (5 items). Each item was evaluated on a 5-point Likert scale, and a higher score indicated greater resilience. The Cronbach's α of the tool used in this study was .93.
3) Organizational socialization
The organizational socialization of new graduate nurses was measured using a tool developed by Chao et al. [21] and translated into Korean by Song and Kim [22]. Among the six socialization domains of the original tool, this study used performance skill (5 items), organizational purpose and value (7 items), and interpersonal relationships (6 items), which were described as the key factors of the socialization process by Chao et al. [21] and are considered antecedents with direct effects of preceptors' teaching behavior. Each item was evaluated on a 5-point Likert scale, with higher scores indicating higher organizational socialization. Cronbach's α for the tool used in this study was .91.
4) Intention to stay
Intention to stay was measured using a tool developed by Cowin [23] and translated into Korean by Kim [24]. The tool comprised 6 items evaluated on an 8-point Likert scale, ranging from “strongly disagree” (1 point) to “strongly agree” (8 points). A higher score indicates a higher intention to stay for new graduate nurses. The Cronbach's α of the tool used in this study was .95.
4. Data Collection
Data were collected at two timepoints: April 2020 and April 2021. The researcher visited the Department of Nursing at the target institution, explained the study purpose and method, and obtained approval and consent for data collection. The research assistants were trained on the data collection procedure. The research assistants explained the research content and rights to the participants. A written consent form was obtained from each participant who voluntarily agreed to participate. In addition, the survey was conducted on weekends and holidays, when managers and preceptors were free and did not feel intimidated by their workload.
5. Data Analysis
Data were analyzed using the PROCESS macro 3.5 program for IBM SPSS 26.0. Descriptive statistics were conducted to analyze the general characteristics, preceptors' teaching behavior, resilience, organizational socialization, and intention to stay of the participants. The reliability of the measurement tools used in this study was presented using Cronbach's α value. Independent t-test and one-way ANOVA were conducted to analyze differences in the intention to stay of the participants according to their general characteristics. Pearson correlation coefficients were used to analyze the relationship between preceptors' teaching behavior, and resilience, organizational socialization, and intention to stay perceived by the participants. To assess the mediating effects of resilience and organizational socialization on the relationship between intention to stay and preceptors' teaching behavior perceived by the participants, a double mediating effect analysis was conducted using model 6 of SPSS PROCESS Macro. To determine the statistical significance of the indirect effect, bias-adjusted bootstrapping was performed 10,000 times with a 95% confidence interval.
6. Ethical Considerations
This study was conducted after receiving the approval of the IRB of C University (CBNU-201912-HR-0289). The researcher explained the study purpose, procedure, and method to participants, and a written consent form was obtained from those who voluntarily agreed to participate in the study. Participants were informed that the collected data will only be used for research purposes, and that participants can withdraw from the study at any time, and that all data would be anonymized to guarantee confidentiality. Completed questionnaires were collected in sealed individual envelopes on the data collection days. The collected data were entered into a database with no method for identification of personal information, and the completed questionnaires were locked in a cabinet.
1. Differences in Intention to Stay, according to General Characteristics of New Graduate Nurses
A total of 167 participants were included in the final analysis. Approximately 84.4% of the participants were female. The mean age, average number of preceptors, and mean orientation period was 25.01 years, 1.38, and 10.52 (range 3~12) weeks. No significant differences were noted in the effects of all general characteristics on the intention to stay of participants (Table 1).
Table 1
Differences in New Graduate Nurses' Intention to Stay, according to General Characteristics (N=167)
2. Correlation between Levels of Preceptors' Teaching Behavior, Resilience, Organizational Socialization, and Intention to Stay in New Graduate Nurses
Table 2 shows participants perceptions of preceptors' teaching behavior, resilience, organizational socialization, and intention to stay. The average preceptor's teaching behavior, resilience, organizational socialization, and intention to stay perceived by participants was 3.84 (out of 5 points), 3.67 (out of 5 points), 3.38 (out of 5 points), and 5.16 (out of 8 points) points, respectively. The correlation between preceptors' teaching behavior, resilience, organizational socialization, and intention to stay perceived by the participants shows Table 2. Preceptors' teaching behavior had significantly positive correlations with resilience (r=.50, p<.001), organizational socialization (r=.34, p<.001), and intention to stay (r=.35, p<.001). In addition, resilience showed significant positive correlations with organizational socialization (r=.62, p<.001) and intention to stay (r=.46, p<.001). Organizational socialization showed also significant positive correlation with intention to stay (r=.41, p<.001).
Table 2
Correlation between Preceptors' Teaching Behavior and New Graduate Nurses' Resilience, Organizational Socialization, and Intention to Stay (N=167)
3. Double Mediating Effects of Resilience and Organizational Socialization in the Relationship between Preceptors' Teaching Behavior and New Graduate Nurses' Intention to Stay
Prior to testing the effect of the variables, the preceptor's teaching behavior, intention to stay, resilience, and organizational socialization measured variables recognized by new graduate nurses satisfied the normal distribution, and the variance inflation factor (VIF) did not have a variable exceeding 10, and the tolerance limit was also greater than 0.1, so there was no problem of multicollinearity problem. No variables were adjusted as covariates because there were no personal and job characteristics that showed a statistical difference in the intention to stay of new graduate nurses.
Table 3 shows results of the analysis conducted using model 6 (2 mediator) of PROCESS macro to evaluate the double mediating effects of resilience and organizational socialization in the relationship between preceptors' teaching behavior and intention to stay of new graduate nurses. Preceptors' teaching behavior had direct positive effects on the resilience of new graduate nurses (β=.50, p<.001), and resilience had direct positive effects on organizational socialization (β=.60, p<.001) and intention to stay (β=.25, p=.008). Additionally, the organizational socialization of new graduate nurses had significant direct effects on intention to stay (β=.20, p=.021). However, the direct effects of preceptors' teaching behavior on the organizational socialization of new graduate nurses were not significant (β=.04, p=.591). The total effect of resilience and organizational socialization in the relationship between preceptors' teaching behavior and intention to stay of new graduate nurses (β=.35, p<.001) was greater than the direct effects of preceptors' teaching behavior on the intention to stay of new graduate nurses (β=.16, p=.044), thereby confirming the mediating effects.
Table 3
Total, Direct, and Indirect Effects of Preceptors' Teaching Behavior on New Graduate Nurses' Intention to Stay (model 6)
To evaluate the significance of the mediating effects (indirect effects) of resilience and organizational socialization on the effects of preceptors' teaching behavior on the intention to stay of new graduate nurses, bootstrapping was conducted 10,000 times. The simple mediating effects of resilience in the relationship between preceptors' teaching behavior and intention to stay of new graduate nurses was Indirect 1 (X→M1→Y) of .13 (.05~ .56) with no zero in the upper and lower limits of the bootstrap at 95% confidence interval, thereby suggesting the mediating effects may occur. The simple mediating effects of organizational socialization in the relationship between preceptors' teaching behavior and intention to stay of new graduate nurses was Indirect 2 (X→M2→Y) of .01 (-.05~ .09) with zero in the upper and lower limits of the bootstrap at 95% confidence interval, thereby showing that the mediating effects were not significant. The double mediating effects of resilience and organizational socialization in the relationship between preceptors' teaching behavior and intention to stay of new graduate nurses was Indirect 3 (X→M1→M2→Y) of .06 (.01~ .31) with no zero in the upper and lower limits of the bootstrap at 95% confidence interval, thereby suggesting the mediating effects may occur. The causal relationship between preceptors' teaching behavior and the resilience, organizational socialization, and intention to stay of new graduate nurses is shown in Figure 1.
This study contributes to the understanding of how the preceptors' teaching behavior, which is a key factor for the organizational adaptation of new graduate nurses, affects resilience, organizational socialization, and intention to stay among new graduate nurses. Based on the current study results, preceptors' teaching behavior, as perceived by new graduate nurses, had an average score of 3.84 points out of 5 points. This is lower than the 4.26 score in a study conducted on new graduate nurses in Taiwan by Lee-Hsieh et al. [10], who developed a tool for measuring preceptors' teaching behavior. However, the score was similar to the 3.88 points observed in a study by Jung et al. [6], who used a Korean version of the preceptors' teaching behavior measurement tool. The Korean government initiated the “Educational Nurse Practitioner Program” pilot project in 2019 to promote the organizational socialization of new graduate nurses, thereby improving the quality of nursing and increasing nursing manpower. In addition, the “Guidelines on New Graduate Nurse Education and Management System” developed by the Korean Nurses Association [25] recommends improving education, job support, socialization, learning, resolving conflicts, communication, and clinical performance capacity of new graduate nurses, and encouraging mentor roles, such as emotional support, counseling, career management, and motivation. The current study findings regarding preceptors' teaching behavior are aligned with the suggestions provided in the aforementioned guideline. Song et al. [7] reported that the recent “Education Nurse Specialist program” was effective for reducing the transition shock of new graduate nurses and increasing social support for enhanced organizational socialization. The education program must be evaluated continuously to further increase the positive effects.
Until recently, most training programs for new graduate nurses provided by medical institutions in Korea focused on improving the practical skills of nurses and failed to reduce the turnover rate of new graduate nurses [26]. Although it was introduced fairly late, the “Education Nurse Specialist program” has been implemented in Korea to increase the adaptation of new graduate nurses to the organization since 2019 by providing financial support to new graduate nurses for a three-month training period. This program comprises 2 weeks of nursing administration and computerized training, 3 weeks of core clinical skills and patient management training, and 7 weeks of 1:1 training with preceptors in assigned wards.
In other countries, various programs are offered to help new graduate nurses adapt to hospitals. In the US, the “Nurse Residency Program” expands for a duration of approximately a year [13]. The Nurse Residency Program (NRP) is designed to expand clinical and professional nursing competencies. NRPs focus on areas of concern for new graduate nurses, such as critical thinking, psychomotor skills, communication, and teamwork. At NRP completion, nurses perceived significantly increased confidence in their leadership abilities, organization and prioritization skills, communication skills, and ability to provide safe care [13]. In Australia, the “Transition Program” is conducted for a period of one year [26]. The Transition Program was developed to foster competence and confidence in new nurses, facilitate professional adjustment, and develop commitment to a career in nursing. Successful transition programs encourage new graduate nurses to remain in the workforce.
In Canada, the government supported “Nursing Graduate Guarantee Program” is provided in medical institutions for three to six months to support the clinical adaptation of new graduate nurses [27]. According to the Nursing Graduate Guarantee (NGG) guidelines, institutions must provide new graduate nurse with a minimum of 12 weeks of extended orientation that includes at least three to six days of general orientation to the organization. During the extended orientation, new graduate nurses are assigned to preceptors who provide daily supervision and guidance in all aspects of direct patient care. The new graduate nurses participated in the care of patients assigned to their preceptors and did not receive separate patient assignments. The NGG program had a positive effect on key dimensions of care delivery, such as decision making, communication, care management, system integration, and commitment, which significantly influences the overall quality of care [27]. Therefore, although experts in various countries have different opinions regarding the training period for the adaptation of new graduate nurses, experts have suggested that new graduate nurses require official support from preceptors or mentors for at least the first 6~12 months [3].
The current study results show that preceptors' positive teaching behavior had significant effects in increasing the resilience of new graduate nurses, and resilience had the mediating effect of increasing organizational socialization. These findings were consistent with those of a previous study, wherein resilience promoted a positive psychological state for successful coping with stressful situations, thereby leading to the mediating effect of increasing organizational socialization [28]. Therefore, resilience becomes a potential advantage for new graduate nurses to resolve problems in clinical practice and enhance positive emotions to promote organizational socialization and intention to stay [29]. This finding indicates that close relationships between new graduate nurses and preceptors lead to increased resilience for new graduate nurses to overcome the transition shock in a new environment and further promotes organizational adaptation. Resilience is an acquired factor that can be altered. Through learning and intervention programs, resilience helps to manage stress, prevent burnout, and affect organizational socialization [14, 29]. Therefore, training and education programs for both preceptors and new graduate nurses will enhance the resilience of new graduate nurses.
In this study, preceptors' teaching behavior had no significant direct effects on improving organizational socialization. This finding shows that a short period of 7 weeks with preceptors is insufficient for new graduate nurses to have high job performance, represent the goals and values of the organization, and develop confidence as a team member. Little et al.[30] emphasized the need for continuous structured support of training by a mentor for at least one year to achieve and maintain the successful role transfer and organizational socialization of new graduate nurses. Nurses who lack organizational socialization experience negative job consequences, such as turnover, work conflict, and reduced productivity. Therefore, developing and applying a successful organizational socialization program for new graduate nurses, such as improved education programs and extension of the training period, are crucial steps [7].
Positive preceptors' teaching behavior led to increased resilience of new graduate nurses and promoted organizational socialization, thereby increasing their intention to stay. This finding shows that the positive role of preceptors is effective in the transfer of roles to new graduate nurses. New graduate nurses experience stress and frustration in the interaction relationship due to ineffective preceptors' teaching behavior, and this may also cause new graduate nurses to change their jobs [18]. Preceptors' desirable teaching behaviors that support new graduate nurses is a key factor that improves the clinical performance of new graduate nurses, promotes organizational socialization, and positively affects their transition into professional nurses [3, 10]. By using structured training programs, well-trained preceptors increase the resilience of new graduate nurses, which further improves their work and organizational adaptation as well as retention rate [5]. Therefore, preceptorship programs for new graduate nurses should be revised to support the socialization and transition of new graduate nurses to professional nurses and increase the knowledge required for work and intention to stay.
Since this study was conducted on new graduate nurses who received preceptor training for two years, the effects of organizational or social environment changes on new nurses'resilience, organizational socialization, and intention to stay during the survey period cannot be excluded. Additionally, as the clinical career of new nurses increases, the influence of the preceptors' teaching behavior on new nurses may be different. Therefore, future research should compare the effects of preceptors' teaching behavior according to the career classification of new graduate nurses. Finally, since the preceptor's teaching behavior applied in this study was developed based on the teaching behavior desired by new nurses in other countries, it is necessary to develop a tool for new Korean nurses and conduct a study using that tool.
In clinical practice, preceptors provide technical education on the nursing tasks of new graduate nurses. Recently, preceptors are increasingly required to have knowledge on various teaching methods and communication to help new graduate nurses adapt to the new work environment and perform the tasks of a counselor. Moreover, preceptors must provide appropriate and evidence-based feedback as well as objective evaluation for new graduate nurses to understand their strengths, weaknesses, and possible improvements [6, 9, 10]. This highlights the necessity for preceptors to deliver their positive experience and knowledge and provide respect, support, solicitude, enthusiasm, and education to new graduate nurses [10].
In Korea, systematic training programs for new graduate nurses are yet to be established. Therefore, collaborative efforts, such as continuous government policy support and active cooperation with medical institutions, are important for ensuring that new graduate nurses can successfully adapt and contribute to the public health by continuing their career in nursing. In addition, the effects of successful preceptor teaching behavior programs must be shared worldwide to ensure the successful careers of new graduate nurses [7]. Although this study only reflects the characteristics of a single medical institution, this study is meaningful because the findings show that that positive preceptors' teaching behavior is a key factor in increasing resilience and organizational socialization of new graduate nurses for increased intention to stay.
Preceptors' teaching behavior promoted the organizational socialization of new graduate nurses by enhancing their resilience and positively affecting their intention to stay. Therefore, in medical institutions and nursing organizations, preceptors not only serve as technical educators who educate new graduate nurses on their clinical performance, but also support the resilience and organizational adaptation of new graduate nurses. An educational program must be developed with the aim to improve the competency of new graduate nurses as role models and to further promote the pride of new graduate nurses as nursing professionals.
In order for new graduate nurses to successfully adapt to the organization and maintain their careers, it is necessary to develop a preceptorship program with a sufficient training period that reflects the needs of new graduate nurses. Additionally, to reduce the high turnover rate of new graduate nurses, the contents and effects of new nursing programs must be shared among countries worldwide. The findings of this study provide the basis for policy support plans and systems that can improve the intention to stay of new graduate nurses worldwide and reduce the turnover rate by evaluating the effects of appropriate training period, competency of dedicated personnel, and training programs for new graduate nurses.
