Dr. Dyess is Project Director, Novice Nurse Leadership Institute; and Teaching and Research Associate, Florida Atlantic University, Christine E. Lynn College of Nursing, Boca Raton, Florida. Dr. Sherman is Robert Wood Johnson Executive Nurse Fellow; Director, Nursing Leadership Institute; and Assistant Professor, Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida.
The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.
Address correspondence to Susan M. Dyess, PhD, RN, Florida Atlantic University, 777 Glades Road, Christine E. Lynn College of Nursing NU357, Boca Raton, FL 33431.
The practice readiness of new graduates is a topic that generates lively conversation and divergent viewpoints among nurse educators in academic and practice settings. Although the phenomenon of reality shock has been acknowledged as part of the new graduate nurse transition for decades (Kramer, 1974), there is evidence to suggest that the problems with the transition into practice are more serious today. Prior to the initiation of computerized licensure testing in 1994, new graduates entered practice with provisional licenses, working with seasoned nurses for a number of months. New graduates in today’s environment can take the licensure examination within weeks of graduation and enter practice as fully licensed registered nurses almost immediately. An unintended consequence of this change has been the rapid deployment of new graduates into clinical settings where they assume professional responsibilities that potentially are beyond their capabilities (Burns & Poster, 2008; Del Bueno, 2005; Li & Kenward, 2006; Spector & Li, 2007). This change has been made even more problematic by the rising acuity of today’s hospital patients, reduced lengths of stay, staffing shortages, and complex new technologies. In this era of cost containment, there have been greater demands on nurse leaders in practice settings to shorten new employee orientations and move new staff into patient care assignments more rapidly.
Health care agencies and the American Association of Colleges of Nursing (AACN) now realize the effect of the influx of new graduates, and many efforts are being made to improve the orientation of novice nurses (AACN, 2005; Salt, Cummings, & Profetto-McGrath, 2008; Williams, Goode, Krsek, Bednash, & Lynn, 2007). The National Council of State Boards of Nursing (NCSBN) has developed an evidence-based regulatory model for transitioning new nurses into practice that they hope to see adopted across the United States through licensure regulation (NCSBN, 2008). It is the vision of the NCSBN that new graduates will be required to provide their state board of nursing with evidence of completing all of the requirements of this standardized transition program to maintain their license after their first year of practice.
With this heightened interest in transition programs and possible future regulatory requirements, nurse educators in practice settings are reexamining their approaches to new graduate nurse orientation. This article presents findings about new graduate nurse transition and learning needs from qualitative research conducted in a community-based novice nurse transition program. New graduate nurse transition and learning needs are examined through the eyes of new graduate nurses and the nursing leaders and preceptors who work with them. Recommendations are offered for continuing education initiatives that can be designed to meet these needs.
In the United States, successful completion of a nursing education program and achievement of a passing score on the National Council Licensure Examination-Registered Nurse are required to demonstrate entry-level competence to begin nursing practice (NCSBN, 2008). Although newly licensed nurses have achieved the legal and professional requirements of minimal competence to enter practice, studies indicate that many new nurses lack the clinical skills and judgment needed to provide safe, competent practice (Del Bueno, 2005; Li & Kenward, 2006). New graduates express concerns about their ability to provide safe patient care and meet the performance expectations of the organizations that employ them (Casey, Fink, Krugman, & Propst, 2004; Duchscher, 2001; Halfer & Graf, 2006). These concerns are shared by nursing leaders. In a recent survey conducted by the Advisory Board Company, only 10% of hospital and health systems nurse executives believed that their new graduates were fully prepared to provide safe care (Berkow, Virkstis, Stewart, & Conway, 2009).
Although the transition into practice can be exhilarating initially, the experience often becomes traumatic during the first year as new graduates experience the real world of health care (Duchsher & Cowin, 2004). Community discussions among nursing leaders in the authors’ area related to the apparent disconnect between nursing education and practice led to the development of a grant-supported Novice Nurse Leadership Institute (NNLI) in South Florida. The NNLI is a university-based, but practice-informed 1-year transition program that is now in the third year of operation, with novices attending from 13 partner agencies. The overarching goals of the program are to strengthen the competencies of new nurses along a variety of dimensions, provide ongoing support to reduce turnover in the first year of practice, and create a pool of future nurse leaders to serve the community by developing a leadership mindset in the first year of practice. Feedback from the new nurses about their experiences and transition has been an important part of the project’s success and development. The research presented in this article about novice nurses’ first-year practice experiences and learning needs is based on program evaluations and findings from focus groups conducted between 2006 and 2008 with new graduate nurse participants, preceptors, and nursing leaders.
As initial planning began for the NNLI program, partnership members agreed that the program would not replace individual facility orientation or other unit-based transition initiatives. Rather, it could serve as a strong recruitment tool for high-potential new graduates and augment organizations’ basic orientation efforts. Prior to the beginning of program design, focus groups were held with chief nursing officers, new graduate preceptors who had varied educational preparation, and staff nurses. To better meet the needs of practice environments, focus group participants recommended that content be developed to enhance the clinical judgment of new graduates and increase their confidence with basic clinical skills. Nurse leaders wanted a transition program that would build on what new nurses had learned in their education programs in the areas of patient safety, communication proficiency, delegation, and health care systems thinking.
A review of the literature about new graduate nurses’ learning needs was also conducted. The leadership content was developed using resources such as the American Organization of Nurse Executives competencies (2005) and the Robert Wood Johnson Executive Nurse Fellows competencies (Morjikian & Bellack, 2005). The curriculum was developed to include 20 full-day learning sessions (Sidebar 1) delivered two Fridays each month across 12 months. The live learning sessions were complemented by asynchronous dialogues on a Web-based blackboard site (Sidebar 2).
Novice Nurse Leadership Institute Topics for the 20 Educational Sessions
Self-Knowledge. Incorporates diagnostic tools for a leadership mindset (foundational thinking skills) as well as leadership and personality style.
Leadership. A discussion of leadership theory, definitions, and systems thinking.
Technical Skill Augmentation and Procedural Ease. Simulation and laboratory time.
Interpersonal and Communication Effectiveness. Role-playing centered on interdisciplinary collaborative interaction and challenging patient and family situations.
Clinical Judgment. Discussion of the competencies of patient-centered care, clinical decision-making, and shared decision-making.
Professionalism. Incorporates a discussion of the competencies of advocacy and accountability, linking them to daily practice.
Knowledge of the Health Care Environment. Incorporates a discussion of governance structures and work design.
Cultural Diversity and Sensitivity. Addresses cultural competency in relation to professional colleagues, patients, and their families.
Safe Practice. Highlights the principles of safety as they relate to patient outcomes.
Business Skills and Principles. Incorporates a discussion of health care economics and financing and links these concepts to nursing practice.
Knowledge of Evidence and Research. Incorporates the competencies of systems thinking, health care policy, patient safety, quality, and evidence-based practice.
Strategic Vision: Our Current and Future Health Care World. Considers the regulatory organizations affiliated with health care and their effect.
Creativity and Innovation in the Practice Setting. Considers translation of evidence and incorporates the competency of change management.
Leadership: Leadership Revisited. Incorporates a discussion of each novice nurse’s personal journey in leadership and explores the challenges therein.
Caring for Self. Highlights the importance of intentional self-care for nurse leaders.
Relationship Management. Focuses on the interdisciplinary collaboration that exists within health care and addresses principles of delegation.
Ethical Practice. Addresses the ethics of nursing care and considers dilemmas that exist.
Inspiring and Leading Change. Allows participants to present their evidence-based projects, followed by a group discussion of findings.
Engagement With Nurse Leaders. Offers panels of nurse managers, nurse directors, and chief nursing officers the opportunity to connect directly with new nurses.
Career Success and Advancement. Incorporates the competencies of career planning, professional development, and personal goal-setting.
Reflective Dialogue Questions for Web Discussion
- How are nursing policies determined within your organization?
- How do nurses contribute to the policy-making process?
- From your perspective, what are the opportunities for improvement in your health care organization?
- What types of decisions do you find yourself making most frequently in your practice setting?
- What kinds of clinical tasks are you delegating? How does that work?
- How do you find support for clinical decisions?
- Identify three areas you want to work on for your personal leadership development.
- How does your practice setting use and incorporate research into practice?
- Describe the training your organization offers for cultural diversity.
The program participants were selected by the partner sites using general guidelines developed by the partnership. Participants were graduates with either an associate’s degree or a baccalaureate degree from various educational programs, and all had less than 12 months of practice experience. A high potential for professional and leadership contributions was an attribute that organizations were asked to use in their selection process. Candidates needed to commit to attend all of the sessions and complete an evidence-based project. The first three classes of NNLI included 81 participants. The mean age of the participants was 32 years. Demographic data for the participants is provided in the Table. The novice nurses worked in diverse practice settings, with 80% being acute care community facilities within a range of specialty areas.
Table: Novice Nurse Leadership Institute Participants (N = 81)
New Graduate Nurses’ Learning Needs and Transition Experiences
To better understand the learning needs and transition experiences of new graduate nurses, a qualitative research study was designed involving pre- and post-program focus groups and using hermeneutic analysis. Experienced focus group facilitators with no connection to the program conducted the sessions. Institutional review board approval was granted annually by Florida Atlantic University. Focus group participants were asked a set of semistructured questions (Sidebar 3). Sessions were audiotaped and then transcribed. Key themes and emerging patterns were coded from multiple reviews of data. Seven key themes involving the learning needs of new graduate nurses were identified from the data analyzed. The key themes, along with recommendations to consider when developing new graduate transition programs, based on the lessons learned from this study, are discussed.
Semistructured Questions Used for New Graduate Nurse Focus Groups
- How would you describe yourself as a new nurse?
- What topics/discussion/content areas do you suggest for the Novice Nurse Leadership Institute program to support you in your practice?
- What are some of the best things and worst things about being a nurse?
- What is going on in your practice setting?
- Describe your typical workday.
- Share some of your new nurse experiences that are memorable.
Confidence and Fear
When asked to share their experiences as new graduate nurses, the participants reported feeling both confident and fearful. One participant described her experience as a new nurse as: “Excited and scared, definitely scared, very excited and good to be where I am and happy to be with the patients, but definitely scared also.” Another participant shared her understanding of the new nurse experience as a synthesis of knowledge and emotion: “And I find it’s a fusion, a mix of fear for being the responsible one, and a challenge; to put all my knowledge properly together in every situation, and then it’s a wonderful achievement.”
The combination of fear and confidence appears to stem from recognition of all they had learned in their educational programs and an anticipation of the unknown in patient situations. The participants also spoke of their determination and commitment to “do their time, whatever it takes” as a new nurse to transition successfully into practice. They expressed confidence in their own abilities and hope that there would be organizational systems in place to support their emotional growth in areas where they needed development.
Recommendation: Support Throughout the First Year. New graduate nurse transition programs are typically designed to be completed within 3 to 6 months. The current findings suggest that new graduates would benefit from longer-term support that includes further development of clinical judgment, debriefing opportunities, and skill set enhancement. One nurse described starting as a nurse: “It’s really like you’re acting like a nurse, but you’re not really a nurse.” This recommendation for long-term support is consistent with the theoretical stage of acquiring clinical competence that acknowledges that novice nurses do not have the explicit understanding of the brand-new situations in which they are expected to perform (Benner, 1984).
Further, the current findings support the conceptual framework of new graduate nurse transition proposed by Duchscher (2008), which suggests that new graduates move through three stages (doing, knowing, and being) during their first 12 months of practice and need support during each stage. During the course of the NNLI, the new nurses were observed to move in and out of phases, and they ultimately recognized the benefit they received from the consistent collegial support provided by the program. The importance of long-term support was prominently illustrated by this statement made by a nurse as she exited the NNLI: “If it weren’t for this NNLI, I never would have made it as a new nurse. Never.” Extended support throughout the first year that respects the developing skills of the new nurse and allows for honest reflection on practice in group discussions with other new graduates is recommended.
Less than Ideal Communication
New graduates in the focus groups reported frequent experiences of less than ideal communication with physicians and other interdisciplinary team members. One novice shared an experience that many other participants agreed had also happened to them: “And so finally I got him on the phone and started to explain the patient situation. He immediately cut me off and said, ‘I am making rounds. It can wait until I get there.’ And that was it. He hung up. I was simply reporting an abnormal lab value, trying to advocate for my patient. The response was so rude. You would think I did something wrong.” The lack of professional confidence that new graduates often feel can be heightened when another professional uses a gruff tone or expresses disgust. This is a patient safety issue because this sense of insecurity can contribute to the novice electing to avoid contacting the physician unless a patient experiences an extreme physiological decline (Rosenstein & O’Daniel, 2008).
New graduate nurses also expressed concern about their ability to supervise and delegate to unlicensed assistive personnel. They reported situations in which individuals refused to cooperate with requests for assistance or passively ignored call bell lights. The new graduates were unprepared to deal with this type of conflict. One novice nurse reflected: “I would rather just ignore them and do it myself than get into it with someone.” All agreed that at some point they experienced a situation in which unlicensed staff did not respond to their requests and they chose not to confront the situation. Many commented that they did not feel equipped to explore the conflict appropriately and professionally.
Recommendation: Interdisciplinary Communication Skills. As part of their orientation, new graduates typically receive some training in interpersonal communication skills. The current findings indicate that they need enhanced communication skill training that includes interdisciplinary role-play conversations and conflict resolution. New nurses benefit from intentional preparation for crucial conversations with other health care providers. Simulations that illustrate and give new graduates opportunities to practice collegial and professional communication in a safe setting, with debriefing and feedback, are very helpful. This need is illustrated by a new graduate who reported: “I want to know that I could respond to them, and know that I could stick up for myself, and that I have the right to, and know the words to say to them.”
Experiencing Horizontal Violence
New graduates in the current study reported frequent experiences with horizontal violence in the workplace. Horizontal violence is defined as any act of aggression demonstrated by a colleague, and it is inclusive of emotional, physical, and verbal threats, as well as innuendo or criticism (Longo & Sherman, 2007). In each focus group session, one participant would typically initiate the sharing of a difficult situation that occurred, and then choruses of NNLI participants confirmed that they too experienced unsupportive and unkind nurses in their practice settings. “It is the attitudes. It’s bipolar sometimes. Like you don’t know if they are having a bad day or if . . . they are happy or not or should it be like this or that . . . . They talk about the night shift, the day shift. They talk about you. They’re mean.” Although leaders in organizations tell new graduates that they promote zero tolerance of horizontal violence, the new graduates observe that this behavior continues and is often tolerated by nurse leaders at the unit level.
Recommendation: Provide Strategies for Responding. New nurses may be unprepared to react appropriately to acts of horizontal violence. Specific information about horizontal violence should be shared with them, along with strategies for how to respond. It is important for transition programs to include scripted responses for new graduates to use in these situations; in addition, an opportunity should be provided for practice and role-play.
Perception of Professional Isolation
Today’s health care environments are often extremely chaotic. In the midst of the chaos, new graduates can feel overwhelmed and professionally isolated. The new nurses reported multiple occasions when they perceived themselves as being utterly alone in their role as nurse, and these experiences influenced them greatly. This is illustrated by the comments of one nurse in a focus group: “It was a bad experience for me. The unit was so busy and no one stopped to notice anyone else. I felt so alone.” Another nurse shared a vivid description of not knowing what to do in a patient situation and seemingly not having anyone to guide her because everyone else was busy and she was on night shift.
Recommendation: A Link to Leadership. New graduates have reported that they feel less alone when they have direct contact and conversations with nurse leaders in their organizations. As is true of other members of their millennial age cohort, new graduates want visibility and transparency from their nursing leadership. A formalized link to high-level nursing leadership enables new graduates to receive constructive feedback and promotes mutual professional dialogue. One nurse stated in a focus group: “I know that our chief nursing officer would be a little surprised at the experiences. I think if she heard first-hand how we feel, maybe that would help with some things in the hospital.” We have learned that intentionally connecting new nurses to successful and seasoned nurse leaders helps them feel less isolated and provides them with guidance on how to seek assistance when they need it.
Complex Units Require Complex Critical Decision-Making
New nurses today often work in specialty settings with complex patients whose care requires high-level decision-making skills. At the time they entered the NNLI, the new nurses in this study were all practicing for 12 months or less, with a mean of 6 months. Of the 81 nurses who contributed to the focus group data, 77% (n = 62) were employed by and practiced in units that are considered specialty areas. Their descriptions of a typical workday indicate that they are involved with multiple demanding patient situations that require high-level critical clinical judgment on a regular basis. One nurse described her day: “Sometimes you have three people dying at the same time. That’s just the way it is. And you need to deal with it all day long. Just accept it. Work with it . . . .”
Many of the nurses reported that they had been in situations in which they were expected to make important decisions regarding patient care quickly and did not have the opportunity to think through the decision. One nurse remarked: “You’ve got to keep going. There is no time to stand still and use your brain.” Another new nurse shared: “It’s hard because you are running around all night and the people are so sick and you don’t even get to stop and think through what you have done.” These complicated environments require critical thinking and clear judgment to support safe and quality care, yet opportunities for reflection on practice are rare. New graduates often feel unprepared or unable to meet these challenges.
Recommendation: Extended Transition Support for Specialty Units. Historically, new graduates were initially assigned to general medical-surgical units. Today, for a variety of reasons, new graduates are often selected for positions in high-acuity specialty areas. Organizations typically provide extensive specialty education related to technology and disease management. In addition to this specialty orientation training, the study participants described a need for transition support that includes opportunities to process emotionally the intense patient situations encountered in these units. New graduates need periodic professional evaluations to ensure emotional acclimation to the intensity of the practice environment. This transition support is needed well beyond the first year. As one new nurse stated: “So pushing the baby birds out of the nest to see if they’ll fly isn’t the best plan for ensuring competent and safe care.” To promote quality care and competent outcomes, Tobin (2007) advocated for a clear collaborative partnership among continuing education, practice units, and new nurses entering those areas.
New nurses have many questions when they enter practice and often seek the advice of other professionals. They reported in the focus groups many instances when they received contradictory information from colleagues. One participant expressed her desire for more clarity in the guidance she was given: “I have a lot of questions and I like to be able to sit with someone and answer those questions, not get everyone’s opinion and then be more confused than ever.” Another commented: “There are so many questions and concerns as well as guidance that I am still looking for, and I seem to be given the wrong answers by some of my staff.” Given the pace of some clinical environments, new nurses are expected to make clinical decisions quickly, yet they find this difficult when there are conflicting viewpoints from colleagues. They also reported that organizational policies and procedures on which they rely for guidance were not always accessible quickly.
Recommendation: Consistent Preceptors Who Focus on the Positive. Through the eyes of new graduates, assigning the new nurse to one individual and “their schedule” improves the consistency of the preceptor experience. Having one preceptor reduces the frustration that new graduates feel as they sift through contradictory information and attempt to learn organizational policies and procedures. The encouragement received from preceptors was highly valued by new graduates. In the midst of the challenges expressed by the new nurses, there were many heartening comments, stories of accomplishments, and reports of professional validation from preceptors. The new nurses recognized moments of professional caring and relished reflecting with their preceptors on the transformative experiences within their nursing practice (Boykin & Schoenhofer, 1991; Newman, 2008). These positive experiences should be shared and celebrated with preceptors and staff within organizations.
Implications for Nurse Educators in the Practice Setting
Ten percent of the current nurse work force employed in acute care settings is made up of new graduates (Berkow, Virkstis, Stewart, & Conway, 2009). The successful transition of these novices into practice is a critical issue for the profession in today’s chaotic health care environment. Nurse educators in practice settings play a key role in designing programs that support new graduate nurses in practice. The findings over the last 2 years with novice nurses suggest that there is a strong need for the content included in the NNLI program (Sidebar 1). The current study also confirms the importance of the essential topics established for the transition modules, which are included in the evidence-based regulatory model for new nurse practice proposed by the National Council of State Boards of Nursing (Sidebar 4). In addition to curriculum content, research supports a need for nurse educators and leaders to advocate for consistent preceptors and extended orientations for new graduates. Opportunities for new graduates to meet with each other and nurse leaders in their organizations are especially important in the first year of practice. The enthusiasm generated during conversations in the NNLI sessions was contagious. A determined effort to focus new nurses on the positive aspects of the nursing profession can successfully extinguish a great deal of the negativity that new graduates often feel, and can promote a smoother transition into practice.
National Council of State Boards of Nursing (2008) Transition to Practice: Recommended Modules
- Specialty training
- Clinical reasoning
- Research use
- Role socialization
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Novice Nurse Leadership Institute Participants (N = 81)
||22 to 59
|Highest level of nursing education
| Bachelor of science in nursing
| Associate’s degree
| Other (Asian, Native American, Indian)
|Clinical area of assignment
| Medical-surgical, oncology, neurology, orthopedics
| Intensive care unit
| Emergency department
| Labor and delivery
| Neonatal intensive care unit, pediatric intensive care unit, pediatrics
| Operating room