Supporting the new graduate nurse in practice
New or novice nurse graduates find it increasingly more difficult to be successful in their role as health care needs and technology expand and cognitive knowledge levels explode. It is therefore not surprising that the most stressful time during a nurse’s career is the first 3 months of initial employment or that 35% to 60% of new nurse graduates change jobs during the first year of employment (Godinez, Schwieger, Gurver & Ryan, 1999). This information is disturbing. What are nursing service agencies doing to support new graduates and what are schools of nursing doing prior to graduation to transition students into practice? To help graduates with the transition, nursing service agencies will traditionally provide new graduates two necessary support programs: job orientation and preceptorship. Orientation programs generally cover job and role expectations as well as orientation to the facility. Orientation programs vary in length and once completed, new graduates are expected to assume a fairly independent practice role. Preceptorship programs commonly assign a preceptor to a novice nurse. A preceptor and new graduate usually work side-by-side or in collaboration for a given period of time, sometimes up to four months. This collaboration period usually coincides with the orientation process.
Schools of nursing are also using various methods to increase new generalist nurse graduates’ success. One strategy some schools have recently initiated is revision or development of new curriculum. Other strategies include internship courses, elective clinical courses and preceptorships. These strategies offer students opportunities to glean “in-the-trenches” type of experiences and to see effective role modeling. Frequently content on “Reality Shock” theory (Kramer, 1974) during the last semester in the nursing program is offered to support students to understand what they will meet in a practice setting. Most nursing programs purport that they prepare nurse generalists and support the fact that a graduate passing NCLEX-RN only indicates that the novice nurse is a minimally safe practitioner. Educators strongly support that content on Reality-Shock (Kramer, 1974) and/or their professional role is adequately addressed in their curricula and thus students should recognize when reality shock hits them in a practice arena. Educators prepare nurse generalists so that upon graduation, with guided learning and time, novice nurses can eventually function independently.
Currently, research related to novice nurses tends to be conducted either by service agencies or by schools of nursing. Topics include role transition, reality shock, experiences of the novice nurse, predictors of performance, occupational stress, plans for success, clinical competence, etc. with a focus either on nursing education or practice. In a literature review, no longitudinal studies were located where the researcher studied students from imminent graduation through their first year of employment. In addition no research reports were discovered demonstrating collaboration between education and service addressing the needs of novice nurses.
Given the current status of education, service and research two general assumptions appear clear: 1) Schools of nursing feel they are preparing and graduating well educated nurse generalists who should pass NCLEX-RN easily since the examination only tests for minimum level of safety and competency. 2) Service agencies sense that having just passed NCLEX-RN, a new graduate should be ready to practice independently after a short orientation period. This demonstrates a gap in expectations. Both education and service question what actions need to be initiated to address the gap. How can both groups participate in the transition period for novice nurses? Given this, a few recommendations are made for both service and education and the collaboration thereof.
Recommendations for Nursing Education
While not all inclusive, suggestions for improvement are provided. Godinez, Schweiger, Gruver and Ryan, (1999) suggest that rather than having internships or capstone clinical courses focusing primarily on nursing care, the concentration should be on the context of and the delivery of care. This approach may provide students a better alternative at identifying the reality of cognitive overload while concurrently studying organization and/or time management. A school of nursing could collaborate with service agencies to develop curriculum for such a course to decrease the “Ivory Tower” aspects and increase the “Real-Trench” aspects (Frock, 1998). This would facilitate collaboration between both educational components and service components to identify reality based signs and symptoms of reality shock/cognitive overload in students prior to graduation, thus giving graduates reality based suggestions to use in practice.
Most schools of nursing utilize post-conferences during clinical courses. One variation is to focus the conference on debriefings of students’ clinical experiences using an Expert Nurse (Benner, 1984), as well as, an expert educator. This seems to accomplish multiple tasks such as increasing students’ contact with expert professionals, increasing collaboration between service and education, and easing students’ transition into the professional role.
Recommendations for Nursing Service
As addressed above, service agencies that utilize preceptors and/ or mentors are extending excellent experiences for novice nurses that lower stress during their transition period. While preceptors are most critical during the first four months of novice nurses’ initial job experiences (Nayak, 1991), it is important that nursing peers also be involved in this partnership. Novice nurses continued to seek support from their nursing peers for an additional fourteen months in their initial job experience (Nayak, 1991), well past the four months when they heavily relied on their preceptors. Service agencies should provide their experienced staff with education to assist them in identifying learning needs of new graduates, which enhances novice nurses’ first clinical experiences and prepares experienced nurses to assist novice nurses. In addition, preceptors should have a reduced patient care load during the preceptorship (Beeman, Jernigan & Hensley, 1999) and reward system should be in place if the novice nurse is successfully integrated into the nursing service agency (Barnum, 1997).
Since cognitive overload may already be present in novice nurses during the orientation process, preceptors need to be inserviced on the signs and symptoms of Cognitive-Overload (Loving, 1997), Reality Shock (Kramer, 1984) and the Trench Factor vs the Ivory Tower Factor (Frock, 1998). Godinez, et al. (1999) and Nayak (1991) recommend that a daily feedback mechanism for information processing and debriefing be in place between the novice nurse and the assigned preceptor. These feedback mechanisms provide a preceptor and agency data regarding novice nurses at risk and information regarding major frustrations for novice nurses.
Since novice nurses concentrate on skills and cognitive recall, they may not focus on other important areas due to cognitive overload. One area of importance during novice nurses’ orientation is learning what their specific agency values. As these values are discussed, novice nurses should be informed that their future evaluations would include a section on how well they meet the agencies’ values. New graduates need to realize that not only are skills included in an evaluation but also such items as critical thinking, time management, communication skills, scope of practice, etc.
Recommendations for Collaboration
Prior to novice nurses’ graduation, schools of nursing and service agencies need to form partnerships to provide students with improved clinical judgment, time management, critical thinking, etc. These partnerships could be offered during the summer months or other times that are not during the normal school semester. One example of several such offerings within the state of Kansas is the newly formed partnership between Fort Hays State University (FHSU) and Hays Medical Center (HMC) for summer clinical student internships. Student nurses earn six college credits and complete 320 hours of clinical experience. Hays Medical Center pays the students a stipend while the educational institution employs the faculty member. The collaboration of Good Samaritan Health Systems of Kearney (GSHS) and University of Nebraska Medical Center College– Kearney Division is another example of education/service partnership. In this partnership students participate in a summer internship of 256 hours. Students earn $6.95 per hour and six college hours of credit all paid by GSHS. For students who enroll in internships, hopefully the outcome will be that students glean excellent experiences and upon graduation experience a less stressful transition into clinical practice.
In addition, this collaboration as discussed above allows agencies to take an active part in the educational process and possibly gain potential future novice nurse employees and thus impact recruitment. There must be a win-win situation identified for each party in every education/service partnership. Additionally, these partnerships need to be evaluated and outcomes published.
Regardless of whether the partnership is between service and a school of nursing or between service and new graduates, a procedure needs to be in place where guided learning such as debriefing and/or journaling occurs. Dialogues (Godinez, et al., 1999) provide novice nurses opportunities to share concerns and frustrations, problem solve and practice conflict resolution.
If more schools of nursing and service agencies engage in partnerships, a solid base could be established for research collaboration. Examples of shared research could include: A longitudinal study to identify signs and symptoms of cognitive overload manifested throughout the last semester of nursing school, completing the NCLEX-RN and throughout the initial job experience for up to ofie year; an inquiry on the effects of education/service partnerships on novice nurse retention; a study of effective orientation programs including an evaluation of quality and length of programs; and, a research agenda studying the impact of educational/service partnerships on novice nurses’ attitudes towards the nursing profession.
In the mean time, what can be accomplished during the period while education and service are developing new partnerships? Both service and education should stay involved in local and state professional education and service organizations alongwith local and state student nurse organizations. These organizations have a positive approach towards working relationships between education and service and give hope for nursing’s future. Above all, such groups tend to position both educational and service nursing professionals in a positive, open stance of “Here let me help you!” for novice nurses rather than a negative, closed attitude of “Here is your assignment, get busy!”
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Beeman, K.L.Jernigan, A.C., & Hensley, P.D. (1999). Employing new grads: A plan for success. Nursing Economic$, (17)2,91-95.
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Reading, VIA: Addison-Wesley Publishing.
Frock, T. (1998). Perception of legal knowledge and skills for Florida professional nursing program graduates: AQ-mythological study. Journal of Nursing Law, (5)4,43-57. Godinez, D., Schweiger,J., Gruver,J., & Ryan, P. (1999). Role transition from graduate to staff
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About the Authors:
Karolyn Kells, PhD, RN, is Assistant Professor and Coordinator of Baccalaureate Outreach Delivery and Graduate Nursing Education at Fort Hays State University. Dr. Kells research interests include nursing education issues, rare disorders, bariatrics and the concept of perception.
Dianna IL Koerner, MN, MS, RN is Associate Professor and Director of Undergraduate Nursing Studies at Fort Hays State University. Ms. Koerner is a member of District 16 of KSNA and is a Board Member of the Kansas Organization of Nurse Leaders. Her research interests include collaboration and partnerships between education and service, bariatrics, and nursing articulation for students.
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