The Journal of Continuing Education in Nursing

Original Article 

Transition to Practice Experiences of New Graduate Nurses From an Accelerated Bachelor of Science in Nursing Program: Implications for Academic and Clinical Partners

Gretchen Wiersma, DNP, RN, CPN, CNE, CHSE; Christine Pintz, PhD, FNP-BC, WHNP-BC, RN, FAANP; Karen Fraser Wyche, PhD, MSW, MA

Abstract

Background:

This study explored the transition to practice experiences of new graduate nurses and the effects of their education on their readiness to practice.

Method:

This phenomenological study used two focus groups to gain an in-depth understanding of the lived experiences of these graduate nurses during their first year of practice, their perceptions of the effectiveness of their academic experience in preparing them for professional nursing practice, and clinical agency support.

Results:

Three themes emerged from the focus group analysis: Practice Readiness, Work-Related Environmental Influences, and Being a Nurse.

Conclusion:

This study provides insight into the key issues surrounding the transition process experienced by new nurses and suggests ways to educate and successfully transition them into professional practice. Information gained from this study provides a beginning evidence base for other educators in both the academic and clinical settings interested in supporting successful transition to practice for new graduate nurses. [J Contin Educ Nurs. 2020;51(9):433–440.]

Abstract

Background:

This study explored the transition to practice experiences of new graduate nurses and the effects of their education on their readiness to practice.

Method:

This phenomenological study used two focus groups to gain an in-depth understanding of the lived experiences of these graduate nurses during their first year of practice, their perceptions of the effectiveness of their academic experience in preparing them for professional nursing practice, and clinical agency support.

Results:

Three themes emerged from the focus group analysis: Practice Readiness, Work-Related Environmental Influences, and Being a Nurse.

Conclusion:

This study provides insight into the key issues surrounding the transition process experienced by new nurses and suggests ways to educate and successfully transition them into professional practice. Information gained from this study provides a beginning evidence base for other educators in both the academic and clinical settings interested in supporting successful transition to practice for new graduate nurses. [J Contin Educ Nurs. 2020;51(9):433–440.]

According to the Health Resources and Service Administration (2014), the numbers of new graduate nurses entering the U.S. workforce has increased from roughly 68,000 individuals in 2001 to more than 150,000 in 2012 and in 2013. Contributing to this increase is the rise in the number of second-degree programs for non-nursing graduates, also known as Accelerated Bachelor of Science in Nursing (ABSN) programs. A recent survey conducted by the American Association of Colleges of Nursing (2019) reports that 23,354 students enrolled in ABSN programs in 2018, which is an increase from 19,541 in 2017. Second-degree accelerated nursing students are described as motivated learners who challenge traditional thinking, have high academic expectations, and bring work experiences that foster their transition to the nursing role (Brandt et al., 2015; Oermann et al., 2010). Yet, even after choosing nursing as a second-second degree and completing an accelerated nursing program, some students may not choose to remain in nursing past one year (Blegen et al., 2017). For example, the 2016 National Healthcare Retention & RN Staffing Report survey of 138 U.S. facilities reported that 29.2% of RNs leave their position within 1 year (NSI Nursing Solutions Inc., 2018). Furthermore, a study of a national sample of 1,653 nurses reported that turnover problems are complex, and there is no one solution to decrease the nurse turnover rate (Brewer et al., 2012).

One proposed solution to the problem of new nurses leaving the profession was to establish a standardized postgraduate nurse residency programs to support new graduate nurses during their transition to practice (The Joint Commission, 2003). Many hospitals have created nurse residency programs that successfully increase the retention rate of new graduate nurses after 1 year (Goode et al., 2013). To determine the extent of the nurse residency program success on the retention rate of new graduate nurses, Ackerson and Stiles (2018) conducted a literature review of 26 studies on the value of nurse residency programs in retaining new graduate nurses. They found that the nurse residency programs did improve the 1-year retention rate, but not after 2 years. Rosenfeld and Glassmen (2016) looked at the long-term effects of nurse residency programs and found that nurse residency programs do have an effect on the retention rate after 1 year, but after 2 years the retention rates may not have anything to do with the nurse residency program but rather other organization or cultural reasons. Although new ABSN programs have successfully graduated new nurses and more nurse residency programs exist, the new nurse turn-over rate continues to be a major challenge for both nursing staff and leaders (Bees, 2017).

Background

ABSN programs have been studied in different ways. Payne's and Mullen's (2014) literature review on a comparison of outcome measures for traditional and accelerated nursing graduates identified four categories of outcome measures addressing both academic and clinical categories. Studies within the review did indicate some statistically significant outcomes, such as a higher grade point average for students in the accelerated program. Results suggested that academic performance was related more to age, with accelerated students being older than students in traditional programs, but they concluded that more research needs to be done toward practice pattern differences. A more recent descriptive cross-sectional comparison study by Read and Laschinger (2017) found that new graduate nurses from both the ABSN program and the traditional BSN program had low intention to leave if they had high levels of interpersonal resources, positive transition experiences, and job satisfaction for nursing as a career. Two studies conducted did address new nurses' perceptions around the clinical practice environment that included Magnet® versus non-Magnet facilities (Hickson, 2013) and the degree to which nurses feel they are able to practice to their professional nursing standards, such as exercising clinical judgment and developing therapeutic relationships (Spence-Laschinger et al., 2016). A recent study by Hatzenbuhler and Klein (2019) conducted individual interviews to explore the perceptions of newly graduated baccalaureate prepared RNs about their educational experiences as prelicensure students in preparing them to enter the nursing workforce. Three themes evolved from the study:

  • Nursing school can't prepare you for everything you need to know.
  • Being in the workforce is different regarding student roles and the role of professional nurse.
  • Some “pearls of wisdom” offered by participants related to these problems.

Overall, the literature on the transition experiences indicates that the transition to practice is difficult for newly graduated nurses. The challenges faced by new graduates have been reported in some literature reviews, such as hostility, both verbally and physically, as well as their inability to practice according to professional nursing standards (Hickson, 2013; Spence-Laschinger et al., 2016). Hatzenbuhler and Klein (2019) conducted individual interviews with new graduates on their postgraduation job experiences and their educational preparation, but these graduates were from six different nursing programs. As such, we cannot say whether program-specific characteristics influenced the nurses' perceptions. We continue to need information from graduates of the same type of program to explore their perceptions about their education, work experiences, facilitators, and barriers encountered as a new graduate nurse.

The purpose of this study was to gain insight into the transition to practice experiences of new graduate nurses from a newly established ABSN program and to explore their perceptions of the strengths and weaknesses of their academic preparation and support received. Exploring this lived experience of the first year in practice may provide relevant information about the transition experiences of ABSN graduates that will benefit the new graduate, the employer, and the ABSN educational institution.

Method

Design

This study was conducted in a large metropolitan area in the mid-Atlantic region. Descriptive phenomenology guided this qualitative study, given its exploratory nature, to understand new graduate nurses' accounts and interpretations of their transition as they moved into professional nursing practice (Polit & Beck, 2012). Descriptive phenomenology aligns with the purpose of this study as it examines the conscious experiences derived from the participant's natural viewpoint while preconceived opinions are set aside (Connelly, 2010; Matua & Van Der Wal, 2015). The focus groups provided an environment for participants to share their experience of being a new graduate nurse. Focus group methodology allows for multiple perspectives to be shared related to the meaning of the experiences of interest and for a topic to be explored in depth (Kerr et al., 2010). Semi-structured, open-ended interview questions were designed to assess the new graduates' perceptions of the impact of their education on their readiness for professional nursing practice. The focus groups provided an environment for participants with the shared experience of being a new graduate nurses, enhancing the quality of a phenomenological study as they allow for a platform for interaction between participants as long as the researcher allows for each member of the focus groups voice to be heard (Bradbury-Jones et al., 2009). During the focus group, the facilitator monitored to ensure that all participants engaged in the discussion; the facilitator provided prompts if needed. All participants were actively engaged in the discussions.

Sample and Recruitment

Purposive sampling was used to ensure a sufficient number of participants. Participants who had approximately 1 year of professional work experience with graduation dates from 2012 through 2013 from a private university were recruited. The ABSN 15-month program graduated 68 students in 2012 and 54 in 2013 with a potential of 122 students for the study. Twenty-five nurses responded to the initial request for participation, but due to scheduling conflicts, the final sample size was nine (N = 9), with six participants in one focus group and three in the second group. The difference in numbers of participants in each of the groups was due to participant availability. Of the participants who participated in the focus group in the fall of 2014, seven graduated in December 2012 and two graduated in December 2013. The participants worked in acute care settings in facilities in a large metropolitan area located near their academic setting and their ABSN program setting.

Data Collection

The two focus groups were conducted on separate days on the academic campus and scheduled for 1.5 hours. The interviews were audio recorded and transcribed. A moderator guide was developed to structure the interview and open-ended questions were formulated to ensure that new thoughts and perceptions were elicited from the participants. Table 1 shows the focus group questions. Data from the first two focus groups were reviewed after the completion of the second focus group. No new data or themes emerged during the second focus group, which indicated that there was saturation (Polit & Beck, 2012). Recent literature supports that relatively few focus groups are needed to generate a majority of new issues in a qualitative study as the majority of the information is brought out in the first few focus groups (Hennink et al., 2019).

Semistructured Open-Ended Focus Group Questions

Table 1:

Semistructured Open-Ended Focus Group Questions

Ethical Considerations

The study was reviewed and approved by the university institutional review board. Informed consent was obtained prior to participation. Participation was voluntary, and participants signed a consent form that assured them that all efforts would be made to maintain confidentiality. At the start of each group, confidentiality was again emphasized with all group members.

Data Analysis

The data analysis was conducted following the steps of Colaizzi's (1978) strategy for phenomenological data analysis (Wirihana et al., 2018). The data analysis began with note taking and recording, followed by transcribing the audio tape into a Microsoft® Word document. Significant statements and phrases pertaining to the transition to practice experience and program preparation were extracted from each transcript and placed into categories by one rater. To ensure rigor, a second rater reviewed the transcripts and coded the data independently. The raters discussed coding differences and reached agreement, with 100% consensus. To help ensure the trustworthiness of the data analysis, we conducted member checking to provide support for the study findings. The research findings were emailed to the participants, asking them to confirm that the themes identified reflected their transition experience. Participants indicated their agreement with the identified themes.

Results

The final sample size of nine included six participants in focus group one and three focus group two. Of the participants who participated in the focus group, seven were from the same class and graduated in December 2012 and two were from the fourth class that graduated in December of 2013; eight were women (89%) and one was a man (11%); ages ranged from 27 to 49 years, with the average being 37 years. Participants were selected based on their educational experience as a graduate from the ABSN program at a mid-Atlantic University, not on their affiliation to a particular hospital. All participants were employed full time and worked in the acute care setting. More than half of the participants worked on the medical–surgical unit (55%), with 33% in the intensive care unit and 11% in the emergency department. Three themes emerged from the focus groups: Practice Readiness, Work-Related Environmental Influences, and Being a Nurse (Table 2). These themes contributed to both positive and a negative transition experience for the newly employed graduate nurses and provided a better understanding about the transition experience and the program's preparation of an accelerated second-degree student for practice.

Themes and Attributes

Table 2:

Themes and Attributes

Practice Readiness

Many participants stated that they lacked confidence in their abilities, especially around organization, technical skills, and medication administration. One student stated, “I think some of the basic tech skills, I don't really feel good about.” Another graduate stated, “I felt the same way about the skills, it kind of makes you feel like you are not ready, or they question your credibility when you are not really sure which way the bedpan goes. I felt that I was not, ‘legit.’” Participants also discussed the aspect of medication administration as being a concern. “Giving meds [medications] safely is a large stressor, if I could just manage my time and give meds safely, I could make it through my shifts without doing much more.” Another participant stated, “In our clinicals, we did not give a lot of meds, it was like once a semester, maybe twice.” However, some of the graduates did feel confident in what they were able to do and perform, stating, “I am so thankful for virtual hospital. When I encountered this one situation that was like virtual, I knew I could do it.”

Work-Related Environmental Influences

Work-related environmental experiences were also found to affect the transition experience. The participants reported experiences that ranged from negative to mixed negative and positive. Negative experiences were associated with communication with family members, physicians, and other nurses. An example was described by one participant:

I had a patient's family accuse me of hurting their family member. Because it is a stressful environment, I didn't think I would find it so often with the family members that they thought the nurses were trying to hurt their family members and are very paranoid. I did not expect this at all. It happens 50% of the time, the family will be suspicious of the nurses and ask if you are trying to make them sicker.

Mixed negative experiences were captured by another participant who stated:

There have been ups and downs in working with families; it really depends on the family. Every now and then you will get a family and you are like “Wow, I am so happy I am a nurse” and then other times I want to jump out of a window.

In addition to their experiences with families, participants also had positive and negative experiences with other nurses. “I felt the nurses were extremely supportive and extremely helpful, and that's where I wanted to work because I had been on the unit for my capstone and very much liked it.” Another student experienced just the opposite: “During my first job, I was hoping that every night I would get MRSA [methicillin-resistant Staphylococcus aureus], so I would not have to go to work. I think it was so much the night shift. I mean it is already crazy busy, and some of the nurses were, ‘oh you don't know that?’ They were just not supportive.” Several participants expressed that their transition from nursing school to professional practice was not smooth.

Three of the participants reported they did not feel supported in their first job and changed jobs within the first year of entering the nursing profession because of bullying or lateral violence. Another student stated, “Working as a nurse is more stressful than I expected it to be and I think it was mainly because of the nurses that I worked with. The people I started with, we were all new grads and we felt like they were just hazing us.” A third student had similar comments: “The night shift where I started was very territorial and the day shift, supportive and excited for me, and it was really hard to break through that hazing or prove whatever they wanted me to prove.”

Being a Nurse

Feeling valued also affected the transition with participants feeling very satisfied assuming the role of being a nurse. One participant stated, “I really feel like I make a huge difference. I made millions for somebody in my previous job, but it did not feel rewarding at all.” Another summed it up by stating, “In the long run, nursing is what I expected and more. I never thought I would be a preceptor because I just like to do things my own way. I get impatient, but after it is all said and done, I like this. We get stressed a lot, but you know, you feel good when you go home.” Another participant stated, “I guess I didn't realize it's physically and mentally a sustained amount of exhaustion. I mean like lifting a patient, how exhausting that can be and can be difficult and terrible like when you need four people to turn a patient…. I guess I knew nurses have a lot of responsibilities, but I did not realize how much of their health really depends on us.” The word compassion even came up, where one participant described the challenges of being compassionate: “For me, sometimes it's so sad and it's hard to let go. There are just some situations that are just so sad, so I've learned through this whole experience [that] when there is a good outcome I cherish it and I put it someplace (touching heart), and it reminds me how I felt, how everything doesn't have to be so sad…. I really cherish those moments.” Another comment about compassion was, “When the family is so grateful and is so nice too, [we get] that little feeling. Or when the baby for the first time eats or…poops, we are like ‘oh my gosh!’ It is really the greatest feeling ever.”

Discussion

These new graduate nurses described their anxiety related to practice readiness and how it affected their confidence as a new nurse. Practice readiness has been defined several different ways within the literature (El Haddad et al., 2017). One way is having confidence in clinical skills and ability to readily assimilate and apply new knowledge (Wolff et al., 2010). Hickerson et al. (2016) reviewed 50 articles and found three themes: The practice gap is real; it is expensive; and changes to undergraduate education are needed to close the gap. The cost can be attributed to workforce turnover with one study indicating an estimated 17.5% of newly licensed RNs leave their first nursing job within the first year, and one in three (33.5%) leave within 2 years (Kovner et al., 2014).

In response to the ongoing practice readiness concerns, The National Council of State Boards of Nursing (2008) has developed an evidenced-based regulatory model for transitioning new nurses into practice that they hope to see adopted across the United States. Even with the regulatory model for transitioning new nurses into practice, they remain underprepared to practice (Kavanagh & Szweda, 2017). A study aimed to understand just what practice readiness meant found that practice readiness revolved around the concept of safe care; performance confidence; and having both the cognitive and clinical capability to perform the role of a nurse (Mirza et al., 2019). Recommendations from the study indicate that clinical partners and academia need to agree on what practice readiness is so they can work in alignment to achieve this goal (Mirza et al., 2019). Work-related environmental experiences were also found to affect the transition experience. Part of the theme related to bullying, incivility, and a lack of support. New graduates are not immune to workplace bullying but often have limited capacity on how to handle such workplace violence (Chang & Cho, 2016). Even with the nurse residency programs to support them during their transition, the incivility continues (Laschinger et al., 2016). Although D'Ambra and Andrews (2014) reported that nurse residency programs assist the new graduate nurse in coping with bullying and incivility and also decrease intent to leave. However, bullying still affects nurses' intent to leave (Sauer, 2018). New graduate nurses switching their job within the first year or leaving nursing because of being bullied in the workplace is an unneeded expense to the health care system and to the new graduate, who has spent much time and money pursuing a career in nursing. Workplace bullying is a threat to patient outcomes and the delivery of quality patient care, not to mention the impact it has on the nurse's personal health and professional well-being (Read & Laschinger, 2013).

The most psychologically damaging form of bullying for a new graduate nurse would be bullying that comes from their peers who are in the same profession. A study of 511 new graduate nurses found that 31% (n = 158) experienced bullying behaviors from another nurse on a weekly or daily basis during a 6-month period (Simons, 2008). Being a new graduate, they seek guidance and mentorship during their transition, not expecting to be bullied by their peers. The metaphor of nurses “eating their young” was most likely created because of the frequency with which it occurs within the profession. Unfortunately, it was experienced by several participants.

One surprising finding was that the participants viewed the patient's family as one of the main sources of bullying. This finding was supported in a study of 135 new graduate nurses identifying bullying from three directions: peers with whom they are working, physicians from whom they take orders, and the families of patient for whom they are providing care (Vogelpohl et al., 2013). Potential conflictual interactions with patient families is one that nursing education health care organizations should emphasize to help prepare new graduate nurses for practice. In fact, new graduate nurses stated this within the study by Vogelpohl et al. (2013). Families are under a lot of stress, and often take out their frustrations on the nurses. Nurses need the skills to manage conflicts and know how to work with families to maintain open communication with the patient. Although one perspective may be to blame the family, families' behavior may be related to the lack of control nurses experience in the hospital. Similarly, the family may lack enough communication with the nurse. This is an important issue because families rely on nurses for information and communication (Ridenour et al., 2017).

The participants stated how important it was to feel valued. Webster et al. (2009) found that feeling valued was largely dependent on the culture of the unit and the organization. To feel valued, individuals need to believe that they are contributing in a meaningful way to the experience, whether the experience is an interaction with a colleague or with a patient. Job dissatisfaction and decreased commitment to the organization can occur when new nurses go home at the end of a shift feeling that they added no value or that they burdened their preceptors by asking too many questions (Romyn et al., 2009).This seems to be especially true of a second-degree student who often chose nursing “to make a difference” (Raines, 2010).

A career in nursing can bring a great deal of personal fulfillment. Howard-Ruben (2002) suggested that the horrendous events of September 11th caused some to reconsider their purpose in life and to choose nursing as a meaningful career to make a difference in the lives of others. Participants talked about the many roles of nursing and just how hard the job can be. Much of it was focused on just how much responsibility the nurse has in caring for sick patients. During their student clinical experiences, they were assigned only one patient, which may have been driven by the need to give clinical experiences to as many as 10 students in a clinical group. A solution may be to decrease the number of students per clinical group to increase the number of patients with whom each student can work. Also, more targeted clinical assignments giving students experiences with patients with psychosocial and family issues would expose the students to the realities of nursing practice. Often, clinical assignments are made to shelter the students from difficult patients; yet, this may not prepare nursing students for practice.

Implications

This study provides information into the transition experiences of new graduate nurses from an ABSN program to their first practice position. The findings imply that some graduates did not feel confident or comfortable in their new role. For many, the transition was not seamless. The participants' descriptions of the challenges they faced may provide the opportunity for educators to make curriculum changes to facilitate the transition process. One such way is incorporating more simulation within the curriculum, using simulation in medication administration, or scenarios around bullying and incivility. Also, increased collaboration is needed between hospitals and educational institutions to first identify what the gap is from both academia and our clinical partners. Identifying the gap could lead to changes within the curriculum, such as more activities on prioritization if this was found to be a gap. It might also maximize the prelicensure clinical experience taking advantage of each clinical experience to address the identified gaps. Experienced nurses working on the floor where students come for clinical can support the instructor in their role and serve as a resource and guide to competent practice. A beginning to this would be meetings to better understand what the clinical partners consider to be the gap in practice readiness. In turn, academia could address the gap through changes within the curriculum.

Study Limitations

One limitation was the small sample size. All participants were employed in the acute care setting. With a larger sample size, we may have been able to recruit participants who were employed in community health settings and who may have had different experiences. Another limitation may have been that the focus groups moderator was the participants' former instructor, which could have led to participants giving more positive comments about the program than they felt. To reduce this concern, participants were instructed that their statements were confidential and would not be attributed to them as individuals. In addition, they were asked to be truthful because the information could be used to improve ABSN programs. Also, they were able to review the themes generated by the focus groups to verify that they reflected the experiences they discussed.

Conclusion

This study adds to the evidence about the transition to practice experiences of new graduate nurses. The participants provided rich descriptions of their lived experiences in their first year of practice. The participants discussed the many positive aspects of their preparation, their job as a nurse, and the challenges of moving from being a student to a new graduate. Recognizing what both the academic intuition and clinical practice partner can do to facilitate successful transition of the new graduate nurse is essential to bridge the gap from theory to practice.

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Semistructured Open-Ended Focus Group Questions

What stands out in your transition period during your first year as a nurse?

How do you feel about your expectations of your new role?

How has your perception of nursing changed since you first started?

What are the weaknesses of the accelerated nursing program in preparing for practice?

What are the strengths of the accelerated nursing program in preparing for practice?

What advantages do you see about the accelerated program in preparing for practice?

What do you see as the disadvantages of the accelerated program in preparing for practice?

Themes and Attributes

ThemeAttributes
Practice Readiness

Feeling confident and trusting in abilities

Ability to assimilate and apply new knowledge

Assertively communicating with physicians

Work-Related Environmental Influences

System that supports and promotes effective communication

Collaborative relationships with physicians and peers

Nurturing and supportive environment promoting independence and autonomy

Being a Nurse

Feeling valued

Compassion

Multiple titles such as advocate or counselor

Authors

Dr. Wiersma is Assistant Professor, Dr. Pintz is Professor, and Dr. Fraser Wyche is Clinical Professor, The George Washington University School of Nursing, Ashburn, Virginia.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Gretchen Wiersma, DNP, RN, CPN, CNE, CHSE, Assistant Professor, The George Washington University School of Nursing, 45085 University Drive, Suite 201, Ashburn, VA 20147; email: gwiers@gwu.edu.

Received: January 21, 2019
Accepted: May 04, 2020

10.3928/00220124-20200812-09

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