In early 1957 a rather notable event occurred in our nursing service; we employed our first graduates of the new two-year program in nursing. These graduates were from one of the local colleges which, in the ensuing years, has been the source of the largest number of our staff nurses prepared in junior or community college programs. We have since employed graduates from about eleven other junior college programs as well. They have come and gone, of course, but some of our early employees from the two-year program type of preparation are still with us. Over the years, we have had about forty-five to fifty-five of these nurses on our staff at all times.
What have been our experiences with nurses prepared in the two-year program? What have we found to be their assets and their needs after they have joined the nursing staff of a large, busy, voluntary general hospital? What have we done to help develop their potential, and to what extent has their potential been realized? How has the two-year graduate reacted to her "coming of age" in the professional milieu? These are questions to which final and complete answers cannot be given, but we have learned a great deal and benefited much from having the associate degree nurse in our midst. In many instances she has achieved real personal and professional growth through employment in our nursing service. The following observations are based on our experiences with these nurses, and we share them with others in the hope that they may be helpful.
Early Needs of the Associate Degree Graduate
What are the needs of the two-year program graduate as she starts her first staff nurse experiences? Fortunately most of these nurses are alert, inclined toward self-analysis, and able to communicate their reactions to new experiences quite explicitly. Thus our impressions of their needs have been formed not only through our observation of their adjustment to our nursing service but through discussions with them.
When the two-year program graduate is asked to look back on her early weeks as a new staff nurse and to tell us what seemed to be her greatest need at that time, she frequently isolates, in a variety of ways, the need to know more about the new world in which she is working. Some brief and general notion of the hospital as an institution has been given her, but its various disciplines and the complexity of their interrelationships are still "terra incognita." Even the organization of nursing service, its traditions, its philosophy, and its working protocol are only vaguely perceived. When the confusions created by realistic operation in contradistinction to ideal or textbook operation are injected into daily work, her need for guidance in this area becomes quite acute.
Stemming from this initial lack of familiarity with hospital life is another area of early confusion. As a student with carefully structured experiences of relatively short duration, she has gained an impression of patient existence in the hospital environment that is incomplete and very different from what she begins to experience as a new staff nurse. The sense of continuity in patient care - the opportunity and need to see the full picture of twenty-fourhour ongoing operation of patient care units - is part of the pressure she experiences for the first time and needs help in understanding.
Another need that the new associate degree graduate voices is how to care for groups of patients rather than for an individual patient. This was isolated by our first group of two-year graduates as their major need and made a great impression on me at the time because, when asked how this experience might be included in their curriculum, they felt that their vacation time in the program might be used to better advantage in getting this kind of experience. And still today, young graduates are recognizing need in this area.
Another need projected by this group of nurses is closely related to the foregoing one; that is, the need to become productive. Learning to care for a larger number of patients and gaining insight and skill in applying fundamentals of good care to several, or even many, instead of one or two patients are real and urgent needs to the new nurse. One member of our original group of two-year program nurses returned to us after several years of experience elsewhere. She was present when we had our first conference with nurses from associate degree programs and was quite vocal about the need to learn how to care for groups of patients. Now, after seven or eight years of nursing, she describes this need as "realizing that you are a 'working gal' and that a day's work really counts." The obligation to be productive and worthy of hire is a broader concept than learning how to nurse groups of patients, but it is all part of the same need. How to develop stamina, how to think and act quickly, and how to concentrate and function in broader areas of responsibility - these are all requirements of being a "working gal" in a busy nursing service situation, and goals that a young nurse needs help in attaining.
Enlarging and perfecting her grasp of nursing care techniques is another area of practice where the associate degree graduate expresses felt need. Not only does the brevity of some learning experiences in her preparation have bearing on this; but changing practices in patient care make it difficult to secure readily these learning opportunities, even for students in programs with longer periods of clinical experience.
Learning how to nurse patients on twilight and night tours of duty is another area of need that is experienced increasingly today by graduates of other types of programs as well as by the associate degree nurse. Shortages of staff do not always allow gradual and protected adjustment to these responsibilities for new nurses. Precipitate and unaided assumption of these responsibilities can be a very traumatic and demoralizing experience for the young nurse. Supervised induction into this area of function after adequate preparation can make it a most meaningful and productive one in terms of professional and personal growth.
Are these needs unique to the associate degree program graduate? Certainly not - these are needs that she characteristically has, but they are evidenced in varying degrees by graduates of other types of programs. The changing nature of patient therapies and the marked changes in basic nursing educational practice are producing a different kind of nurse today. The graduate of a basic collegiate program, when interviewed today, often admits to having great apprehension about her first night duty because she did not have exposure to this as an undergraduate.
Competencies involving patient care techniques and emergency patient situations among young graduates from all types of basic programs cannot be assumed. Much of their knowledge in these areas is often theoretical rather than actual. Varying and changing practices in service agencies, and the limiting effect (breadth and variety of experience) of highly structured learning experiences, are perhaps some of the underlying reasons for this. The problem in induction of the associate degree graduate into nursing service is not one of developing in-service activities with enough flexibility to meet the needs of nurses from all types of programs to the degree that they need assistance in various areas.
Before considering what these activities should be, the other side of the coin should be examined. What are her strengths? Where do her greatest proficiences lie? Again, these observations are made in a general sense, based upon our own experience with these nurses.
Assets of the Associate Degree Graduate
The enumeration of the assets of the associate degree graduate should begin with notation of her competence in the theoretical aspects of nursing. Usually this young nurse has a good grasp of nursing and related medical science. She knows the answers to the degree that they can be found in theory. Perhaps this is the point at which to emphasize another real asset: Not only does she know a good part of the science and theory applicable to her field of study, but she generally knows what she does not know, and she is willing to admit it and to seek help.
The associate degree graduate who joins the nursing staff with this attitude is almost always an avid learner. She has an inquiring mind and can apply processes of reflective thinking to enlarging her knowledge and skills. Rarely do we find among this group any attitudes of boredom, "so whatness," or indifference to educational opportunities. It is amazing to see how interest and some of the wonder of new knowledge gained persist in this group as they mature professionally.
Two other areas where the associate degree nurse usually exhibits strength are those of psychological insight and communication skill. Characteristically, she shows insight into the mechanisms of human behavior in her patients and intelligently and sympathtically observes the changes manifested during the course of illness. While her insight into her own behavior is not always on target, she does exhibit aboveaverage awareness of the dynamics of human interaction in her peer group and among other personnel.
The ability to verbalize what she observes in patients and in the nursing scene in general is again characteristic of her educational preparation. Perhaps oral communication skill is more evident than is her written skill, but again, team conferences and in-service activities give more opportunity to display this. When the nurse from the twoyear program has worked her way up into assistant charge nurse or charge nurse responsibilities, these assets are evidenced again in the reports and evaluations she submits.
Meeting Needs Through In-Service Education
Recognizing some of the needs and assets of the two-year-program graduate, how can the in-service and operational activities of nursing service be adjusted to help meet her needs and develop her potential? It must be remembered that the associate degree graduate is not unique in having needs and being something other than the ideal young staff nurse who, after orientation to the peculiarities of the employing institution, can begin to function with minimal supervision. Graduates of other kinds of programs do not measure up to that specification either; they have genuine needs too, and the variations are those of kind and amount. Rapidly changing practices in kinds of therapies and delegation of different sorts of responsibilities to nurses are making it almost mandatory that every graduate continue to be a student after she assumes the staff nurse title.
Several requisites for induction of new staff nurses into nursing service responsibilities therefore pertain. The program must be dynamic, that is, nonstatic, always experimenting and adjusting to changing needs; it must be flexible enough to enable nurses to gain the amount and kind of help they need. There must be some means by which the young nurse can be helped to assess the amount and kind of help she needs, and then a plan or system to evaluate how well those needs are being met must be developed. Consequently, our in-service activities are modified from season to season, and we are continually searching for better ways to help the new staff nurse develop the skills, knowledge, attitudes, and stamina that the role of the staff nurse in our hospital requires.
Elements of Our In-Service Program
In the past few years our graduate nurse in-service activities have developed on four levels, which may be outlined briefly as follows:
1. Orientation: two weeks of class and conferences for two hours daily, supplemented by orientatation to individual patient-care areas and patients, given by head nurses and supervisors.
2. Tool courses: a two-day workshop in team nursing, unit management, communications, clinical teaching, monthly clinics on nursing care techniques, cardiorespiratory emergencies, IV techniques.
3. General program: usually a once a month program of general interest dealing with new therapies, interesting medical or nursing care problems, etc.
4. Clinical area programs: classes, case presentations, and conferences planned and given in special clinical areas and designed to enable staff members to give better care to their particular kinds of patients. These programs are open to interested staff members in other areas of the hospital.
Last summer we adopted a sequence of planned classes from this program of educational activities designed to help the new nurse acquire the knowledge and insight she needed at or before the time she would be exposed to the need. Previously we had frequently heard the comment that a class or workshop had been enjoyed, but that remark was followed by a fervent, "Oh, if I had only had this before my first tour of night duty or before I had to relieve the assistant head nurse during vacations." Subsequently, we attempted to arrange an initial sequence of educational experiences that would give the new staff nurse as much help as possible in fitting into the role of staff nurse on day duty and in preparing her for the responsibilties she would have to assume when her first tour of night or twilight duty occurred.
Because we try to operate our units on a team nursing basis, we started the modification of our program with a revision of the course on team nursing. Group conference leadership techniques were taken out of the course and incorporated in a new course in communications. In its place the aspect of "team nursing" that deals with team function on twilight and night shifts was amplified. Some of the material from "unit management," essential to assumption of charge nurse functions on twilight and night tours of duty, was woven into the content and activities. The new course in communications was developed to give, in addition to group leadership conference techniques, opportunity to understand and begin to develop some proficiency in interpersonal relationships. Frequently in discussions with auxiliary workers and practical nurses we have heard comments that the young nurse does not know how to talk to us or ask us to do things in a nice way. Trying to develop insight and "knowhow" in dealing with other members of the nursing team and with patients and their families is one of the objectives of this course.
As a cardiac-respiratory emergency team began to function in the hospital and nurses were permitted to do venipunctures after special training, areas of new skills and knowledge had to be brought to the new nurse. Our hospital is an extremely busy one with a high percentage of patients who are acutely ill. It is very difficult to protect the new nurse against involvement in situations of patient-care crises; therefore, we place emphasis on helping her to develop the ability to function in crises as quickly as feasible. Consequently, our new sequence of initial learning experiences, given the availability of doctors who teach courses on cardiorespiratory emergencies and IV techniques, was as follows:
1. First two weeks: orientation- approximately twenty hours; it can be given in a shorter period with small groups.
2. Second week: team nursing - a two-day workshop.
3. Third week: cardiorespiratory emergencies - four to five hours.
4. Fourth week: IV techniques -five hours of class and laboratory followed by supervised experience.
5. Fifth week: communications -two-day workshop.
We have been able to follow this sequence fairly well during the past semester, with the exception of the course on communications. Illness and unexpected home pressures have delayed scheduling of this course as frequently as necessary to ensure that all new nurses have the full sequence of courses. It is somewhat too early to assess the effectiveness of this change in program because all the new nurses involved have not as yet had night or twilight duty.
As new nurses, including our associate degree graduate, progress through the Initial weeks of employment, how do we try to help them assess their needs and direct them to the help which is available? The in-service teachers, of course, have access to the records and credentials of each new nurse. They also keep in close touch with the head nurses and supervisors. Individual and group discussions during and after class are often revealing. In addition, two guidelines (checklists) are given to new nurses after the first intensive weeks of in-service work are completed. One guideline is designed to help the individual tell us what experience she has had and what she feels she still needs in relation to nursing care techniques that are frequently used or are important in less common nursing situations here. The other guideline is designed to help the nurse make the same analysis in regard to patient emergency situations. We try to emphasize our attitudes about graduate nurse education through the use of these guidelines which are given to the nurses to fill out. There is continuous need to learn, the same kinds of therapies are not always used in every hospital, graduates of all programs need help of some kind, and there is no need to feel embarrassed about acknowledging a need and asking for help. The only situation that is undesirable is when one is unwilling to recognize a need and seek help to meet it.
Before leaving the subject of in-service education, the uses of the course on clinical nursing techniques should be emphasized. This consists of monthly presentations by nurses from particular clinical areas of procedures that are used in the care of their patients. The content of these presentations in the course of a year can encompass the entire range of nursing procedures. Precedence is given to certain subject matter areas on the basis of expressed need and reflection of needs through observation or actual mishap in patient-care operations. Attendance is urged but not mandatory. Nurses who are observed to have definite technical needs are urged to attend by their head nurses and supervisors. This course content covers an area of function which may breed malpractice suits, and every effort is made to have nurses with gaps in previous training or experience attend or participate.
Evaluating the In-Service Program and the Associate Degree Graduate
How do we evaluate the effectiveness of these educational activities? As indicated, staff nurse reaction gained through conferences incidental to inservice activities and planned evaluation of courses is important. Occasionally, at monthly meetings with staff nurses, problems relating to adjustment and in-service activities are injected into the discussions. Several staff nurses are members of the In-service Committee, and their reactions are weighed along with those of the instructors in determining what revisions or new directions in in-service activities should be undertaken. Evaluations of professional staff nurses are requested routinely from head nurses and supervisors at the end of three months and annually. Any other time a staff nurse's performance presents problems the head nurse and supervisor cannot deal with, an evaluation is requested. Regular meetings of Head Nurse, Supervisory, and Assistant Director personnel are also forums where the effectiveness of staff nurse performance in general, either directly or indirectly, is evaluated.
The final evaluation of the associate degree program graduate, within the context of this paper, is how she responds to the activities designed to integrate her into the staff nurse group and help her to become a productive professional worker capable of future growth. First of all, in common with graduates of other types of basic professional programs there are excellent, mediocre, and, occasionally, poor nurses in the group. Apparently some factors of individual aptitude, interest, or personality predispose to success in nursing practice regardless of the type of basic education given. In general, though, it has been our experience that the average two-year program graduate in her initial staff nurse job can and does develop into a capable staff nurse practitioner. If she has had previous experience as a practical nurse, this does seem to be a factor in rapid and effective adjustment to staff nursing. The graduate of the associate degree program has demonstrated the ability to grow and to meet higher level responsibilities in some instances. Nurses from this type of program have been promoted on merit to Assistant Head Nurse, Head Nurse, and Supervisory positions here. Characteristically she has been a professional practitioner distinguished by an inquiring mind and a great desire to learn more. Problems that have occurred in regard to attitudes or performance among these nurses usually have occurred with nurses who did not come to our nursing service directly from school. Previous work experiences have intervened.
The attitudes of most of these nurses toward themselves and the job of nursing are commendable. They admit to apprehension about meeting the challenges of real nursing, but their fears are not pathologic. For the most part, they have a realistic comprehension of the limitations of their preparation and their need to continue to learn and gain experience. Most of them have the courage, good sense, and initiative to tackle the job and welcome whatever help or support is offered them.
A few weeks ago, in anticipation oi writing this paper, I asked our head nurses and supervisors during a meeting to give me an impromptu rating of their professional staff members in terms of initial adjustment. The rating choices were three: (1) above average, (2) average, and (3) below average. Deliberately, no mention was made of the purpose behind this questionnaire, and the idea of any possible differences because of type of basic preparation was avoided. They received a piece of paper listing the names of their staff nurses and were asked to rate them in a matter of ten minutes or so. A total of seventy-four evaluations oí two-year program graduates were made. Sixteen, or approximately twenty-one percent, were designated as above average; seventeen, or approximately twenty-two percent, were characterized as below average; and forty-one, or approximately fiftyfive to fifty-six percent, were designated as average. No time limit of an exact number of months was injected into this questionnaire because varying elements of tenure of the nurses were involved, and there seem to be other factors in addition to the basic type of preparation involved in the question of whether nurse X can do the same things as well as nurse Y in a given span of time.
When we have met on different occasions with the staff nurses from associate degree programs to discuss any special needs or reactions they may want to make known (these occasions have usually been before participation in conferences or before the writing of material relevant to these graduates), two characteristics are stressed by the nurses as highly desirable and important in the working situation: openmindedness and freedom to seek help without embarrassment. An ideal working situation to them is one where labels other than "staff nurse" do not matter, where freedom to express need and to secure help to meet it exist, and where recognition is given on the basis of how well and willingly a nurse learns to do her job.
The graduate of the two-year program has acted as a sort of catalyst in the examination of problems and needs of young graduates. The area between competencies of the new graduate and demands for staff nurse function seems to be becoming wider. Because the needs of the two-year graduates are so obvious, and we see her in comparison to two other types of basic program graduates, our attention is focused more clearly on the needs and problems of all nurses. The complexities of the rapidly changing environment in which all graduates have to find their way are more readily recognized, and we begin to make comparative explorations in the whole field of transition from student to mature professional practitioner. This is an area pregnant with meaning for the operation of nursing services and the preparation of nurse practitioners. Definite answers and orderly lines of regimentation in function are sought, but our experiences with the two-year-program graduate indicate that it would be unfortunate and undesirable to establish too rigid organizational lines too early in our quest for professional stability. We are all seeking the best way to produce nurses who will practice nursing in a conscientious, competent, and compassionate way. Our experiences with the two-year graduate have been promising and hint of much more meaningful help to be gained toward our professional objective through working with them in nursing service.