One of the most talked-about topics in recent nursing history has been the problem of role transition of new nursing graduates. Both nursing service and nursing education have identified a mutual disparity between the priorities of the educational program and nursing practice in the clinical setting. Nursing education has become aware of the pressing need to prepare students to make that adjustment to the professional role which is critical to professional role enactment. Specific strategies to assist students in the integration of essential knowledge and skills have been lacking generally in nursing curricula.
As part of a study of both nursing interns and the role transition process itself, a curriculum design to promote role transition among new graduates was developed and implemented in 1978 and 1979 at The Johns Hopkins University Nursing Education Program. Senior students who already had completed three semesters and one summer session of an upper-division nursing program were introduced, during the last semester of the program, to a series of concepts related to professional role enactment. Central to the content areas chosen for presentation in the course were themes drawn from the experience and perceptions of nursing interns in the hospital setting. The problems, conflicts, successes, and opinions of the interns proved to be a fertile source for assessment of the needs of new graduates.
Objectives of the Practicum
The nursing faculty met regularly to plan the sequence of learning experiences which ultimately would become a senior student practicum. Effort was focused on the final senior course which was designed to move the baccalaureate nursing student into effective practice as a beginning staff nurse. The purposes of the course were described as the following;
1. to help the student synthesize knowledge and experience learned in previous courses through multidisciplinary analysis of clinical, human, and organizational forces affecting health care delivery;
2. to clafify and/or plan appropriate responses toward the goal of health promotion of groups of clients;
3. to facilitate the role transition of the student to that of beginning graduate practitioner capable of exercising the responsibility and authority required of a professional nurse accountable to a group of clients and a health care team.
The course also was intended to aid the student in clarifying and integrating a theory of nursing and a professional value system into a client-centered nursing practice in a bureaucratic health care system. This final step in the anticipatory socialization of the student into the professional nursing role was designed to make the transition process an experience which could be dealt with successfully. The emphasis in the course was placed on excellence in nursing practice - which implied intelligent, scientific applications of the nursing process in the humanistic care of patients. It also meant sharing of responsiblity for health care delivery based on the needs of clients and their ability for self -care and on recognition of the contributions of other members of the health team.
THEORETICAL COMPONENT: In an earlier part of the senior year, students had studied leadership theory and related areas of small group process, decision making, and problem solving. The perspectives of various nursing theorists were presented prior to the practicum so that students would have an opportunity to utilize these ideas and concepts in their final clinical experience. This proved to have positive results because a number of students chose to develop care plans, papers, and other course materials within the framework of a preferred nursing scholar. It was expected that classroom content would build on previous knowledge from the social and behavioral sciences, as well as on concepts presented in earlier nursing courses.
CONTENT AREAS: Kramer1 outlined an anticipatory socialization program which she developed at the University of California in 1969 and 1970. Her plan to equip new nurses with a knowledge of the social system of the work organization was intended to help them move effectively into the staff nurse role. In accord with this perspective, a component on role and organizational theories was incorporated into the course, emphasizing an understanding of the social system in which professional role enactment would take place. The hospital and its complex organization was used for illustrative purposes; other types of health care agencies and their organizational structures were analyzed by individual students. Professional and bureaucratic expectations for nursing were contrasted, using examples from clinical practice.
The rights of clients within the health care system as well as the rights of professionals also were identified and compared, using clinical examples. Emphasis in this part of the course was on the ethical and professional staff conflicts which nurses encounter in their own practice. Dilemmas in nursing practice which relate to allocation of resources, professional responsiblities, and nursing input into patient-centered decisions about care were explored in depth. It was made clear to students that answers to all of these ideas were not possible or even expected. Nurses, however, need to have an awareness and concern for their own standards of practice, particularly where nursing plays a critical part in the maintenance of an individual's life.
One area of content, which was developed in depth toward the goal of anticipatory socialization, was the area of conflict management. The concept of conflict was explored in various facets, starting early in the course with the identification of possible role conflict and role strain for nurses in professional practice areas. The topic was enlarged later to encompass conflict arising in clinical practice and generated from any source. Students analyzed conflict which they experienced themselves, as well as other conflicts which were described for them. Strategies for managing common conflicts were identified and evaluated as the strategies were utilized in the various clinical settings. The objective of this part of the practicum was to prepare students for role transition by heightening their awareness of problematic situations. Students' knowledge of small group process, leadership styles, and problem-solving techniques was drawn into play in this component of the course. Difficulties in role enactment, which ranged from problems related to patient care or staffing decisions to global issues related to quality assurance of nursing practice, were analyzed systematically. Students discussed anecdotes, role played, and wrote thoughtful critiques of the particular settings in which they were having their own experiences.
TEACHING-LEARNING ACTIVITY: In the presentation of classroom content, efforts were made to provide a variety of learning activities in addition to the conventional lecture format. Other activities included small group discussions, student presentations, films, clinical seminars, and educational games. One educational game illustrated the group process in decision making as well as bureaucratic considerations in the allotment of resources while another illustrated the power struggles often present between management and the employee.
Within the content area on conflict management, each clinical group was asked to present an example of role conflict which they had encountered during their practice. The major themes identified by the students were the following:
1. conflict between the student's expectation of the patient and the patient's actual performance (e.g., noncompliance in the outpatient setting);
2. conflict between the student's expectation of personal professional performance and what was observed in others (e.g., lack of psychological support provided to families in the intensive care unit);
3. conflict between the student's expectation of personal professional performance and what actually was permitted in practice in the clinical setting (e.g., time constraints imposing on the performance of technical skills in addition to psychological support for the patient and family).
Another class session was devoted to a presentation by several graduates from the preceding year's class. Prior to the class, both the students and the graduates were asked to read articles that described the experiences of recently graduated nurses. These articles provided the basis for beginning discussion and the graduates readily identified experiences of their own that were similar to those described in the articles. Students had ample opportunities to question the graduates as to their usual strategies for conflict management as well as to their future plans in nursing. This seminar reinforced and gave validity to the material presented in lecture.
COURSE REQUIREMENTS: A weekly journal and a paper were the two requirements for the theory portion of the course. Specifically, the journals were to include the following:
GUIDEUNES FOR SUMMARIES OF JOURNMS
1. analysis of clinical practice with identification of weekly goals and evaluation of work accomplished toward the goals. The evaluation was to include a discussion of factors promoting and/or inhibiting goal achievement, as well as a discussion of alternative methods for goal achievement.
2. analysis of role development as a professional nurse in the clinical setting with identification of goals, role conflicts, and alternative methods of management of these conflicts as well as evaluation of the degree of goal achievement in this area.
The weekly journal entries remained confidential between the student and the clinical instructor. However, at the end of the course each student was asked to summarize his/her progress with regard to clinical practice and professional role development. In addition to being an important review of the clinical experience for the student, the summaries were used by the faculty as a means of evaluation of the course. Guidelines for the journal summaries are given in the Table.
The purposes of the course paper were to (1) have the student articulate his or her philosophy of nursing, (2) describe the effect of the student's philosophy on his or her practice and professional role development, and (3) discuss the implications of the student's philosophy of nursing for job selection and career planning. In order to describe the effect of philosophy on practice, the student was asked to describe and analyze an instance in which one's philosophic beliefs created a conflict in enacting the professional nurse role. Two alternative methods for handling the conflict were to be identified and discussed with appropriate support from the literature. For the fifth hour of theory each week, faculty members met with their clinical groups in order to relate the theoretical presentations of the classroom with the clinical activities of the student. Problems of nursing care delivery, strategies for dealing with nursing and medical staff more effectively, and similar topics were pursued in the clinical seminars. In this way the students realized an additional opportunity to integrate classroom learning with their clinical practice.
For the clinical component of the course short descriptions of the varied clinical settings were circulated to the students for their consideration. The choice of clinical sites included inpatient pediatric, medical, surgical, gerontological, psychiatric, rehabilitation, and outpatient primary care settings. The variety of settings offered was based upon a preliminary poli of student interests and availabilities of the faculty. With the help of this preliminary poll, most students were able to have an experience in the setting of their choice.
Clinical experience consisted of 24 hours of clinical time per week for a period of seven weeks. In most settings, experience was provided on three shifts, including an occasional weekend. The course objectives for the clinical component remained the same with varied sites; however, the methodologies employed for meeting the objectives varied somewhat with the setting as well as with the student's own objectives for the experience. In general, attempts were made to increase gradually the responsibilities of the student on the unit to those of a graduate nurse. For example, initially student assignments were "posted" the day preceding clinical experience so that students could prepare adequately for the experience. However, after orientation to the unit, when students individually were judged capable, students received their patient assignments immediately preceding report. In addition, the number of patients assigned to each student also was increased gradually; because of the number of patients cared for by each student, an integral part of the experience was to have a maximum of four to five students assigned to each unit.
Student requirements for the clinical component included two care plans. Care plans included elements of the data base, nursing diagnosis, interventions, and evaluation; these were adapted to the format used by nurses in the student's clinical setting. Care plans were entered directly into the patient's chart or cardex so that they could be shared with other staff members. In this way the care pians were a maximum benefit to the patient and not merely an assignment to be submitted to the instructor.
Student progress was evaluated on the basis of performance in the theory and clinical components of the course. The theoretical grade (40%) consisted of the philosophy paper and journal; the clinical grade (60%) consisted of two care plans and the clinical evaluation. The Slater Nursing Competencies Rating Scale2 was chosen to evaluate clinical performance because of its established validity and reliability, ease of statistical analysis, and application to competencies that one would expect to see in a wide variety of nursing situations.
The role transition course itself was evaluated by both students and faculty. Student evaluation consisted of completion of an evaluation form which provided the opportunity to discuss course content, methods of presentation, application of content to theclinical setting, and strengths and limitations of the clinical sites. Faculty evaluation consisted of informal biweekly conferences during the semester as well as completion of an evaluation form. The evaluation form addressed the appropriateness of clinical and eia ss room ob j ec ti ve s, strengths and limitations of the clinical sites and course in general, and suggestions for further development.
The expressed belief of both faculty and students was that the seven-week practicum, designed to assist senior nursing students to move into the professional role without major adjustments, had a positive effect on students' role transition. Faculty members were able to validate the student's nursing intervention but also allowed the student to assume increasing independence. The growth of students as professional practitioners was evident to themselves and to others. Students' evaluations indicated that role transition was facilitated through assumption of a role as close as possible to that of staff nurse. The support of the faculty member helped the students develop coping and adaptive techniques to deal with the real-world environment of the clinical setting. Students stated that they felt accepted as staff members who were able to make a contribution to patient care.
A concentrated effort to facilitate the movement of nursing students into the professional role can make a difference in a number of important factors. The level of confidence, self-esteem, and self-worth of the students can be buoyed during a difficult time if they have been prepared in theory and in practice to function as beginning staff nurses. To make this happen, faculty members need to set priorities for student learning that will bridge the gap between the student role and the practitioner role. To do less than this would be to ignore the significant concerns of nursing service personnel and of the students themselves.
- 1. Kramer M: Reality Shock: Why Nurses Leave Nursing. St Louis, CV Mosby Co, 1974.
- 2. Wandelt M. Stewart DS: TAf Slater Nursing Competencies Rating Scale. New York, AppletonCentury-Crofts, 1975.
GUIDEUNES FOR SUMMARIES OF JOURNMS