The majority of students entering and completing college and subsequently joining the nursing workforce are currently labeled Generation Z or Gen Z (Goh & Lee, 2018). This cohort of learners born between 1995 and the early 2010s represents a sizable portion of the U.S. population at roughly 24% and will comprise 20% of the workforce in the next 4 years (Chicca & Shellenbarger, 2018; Goh & Lee, 2018). Gen Z are believed to be passionate consumers of technology and true digital natives born into a world with constant access to the Internet and information (Chicca & Shellenbarger, 2018; Christensen, Wilson, & Edelman, 2018; Goh & Lee, 2018). Bathed in technology, Gen Z students are accustomed to interacting in a digital world, considering social media as a normal way to communicate and using Google™ to answer every question (Christensen et al., 2018). As a result of digital immersion, this generation (a) is experiencing underdevelopment of social and oral communication skills, (b) has shorter attention spans and a tendency toward boredom, (c) has greater doubts about succeeding, and (d) are visual learners via observation and practice while also struggling with traditional strategies including lectures and reading (Chicca & Shellenbarger, 2018). As members of a visual generation (Christensen et al., 2018), Gen Z learners embrace videos, pictures, emojis, and memes for communication through applications such as Snapchat, Instagram, and smartphone instant messaging (Christensen et al., 2018; Shatto & Erwin, 2016).
As a generational cohort, understanding these characteristics becomes increasingly important when nursing academicians are attempting to meet learner needs and expectations. Specifically, this generation appreciates active, interpersonal, and hands-on learning opportunities in classroom and clinical settings (Seemiller & Grace, 2017). Faculty teaching Gen Z students should be aware that learners (a) crave digital environments, as on average they spend as much as 9 hours per day online, (b) are independent and practical but concerned with their own safety, and (c) are diverse and open minded but may experience isolation and detachment (Chicca & Shellenbarger, 2018; Shatto & Erwin, 2016). This generation may be slow to launch to independence, may expect faculty to assume a parental role, and desire frequent feedback to build confidence (Shatto & Erwin, 2016). Gen Z students may benefit from blending teaching pedagogies—such as using cognitive and self-regulated approaches and instructional technology—allowing for rapid student feedback (Christensen et al., 2018).
It is important to recognize and validate appropriate learning strategies and approaches in classroom and clinical settings most likely leading to success in this generational cohort. This is critical as there is increasing demand for practice-ready graduates. Recently, immersive clinical approaches, or brief, structured intense clinical experiences where the entire focus is on a particular setting without the distraction of other academic classes, has emerged (Tratnack, O'Neill, & Graham, 2011). Evidence suggests immersion experiences are positively associated with student confidence (Fowler, Knowlton, & Putman, 2018). However, it is unknown whether an immersive approach is optimal in Gen Z students who may struggle with poor communication skills, low self-confidence, and shorter attention spans (Marchex, 2016).
Understanding differences in Gen Z nursing students' attributes—including readiness for practice and anxiety and self-confidence with decision making—may assist academicians in determining the optimal nature and length of practicum experiences for this generation of learners. The purpose of this pilot study is to compare readiness to practice and anxiety and self-confidence during decision making between graduating Gen Z students experiencing a traditional clinical versus an immersive clinical in a baccalaureate program.
Following institutional review board approval, a convenience sample (N = 120) of last-semester senior nursing students enrolled in a baccalaureate program in the Midwest were recruited. Qualtrics® (an e-survey tool) was used to administer a demographic questionnaire, survey, and scale on the last day of the academic year (1 day prior to graduation). Participation in the study was voluntary. A total of 46 students (n = 46) who were predominantly female and White (n = 42) met inclusion criteria (age 23 years or younger). Students followed one of two program options:
- Traditional Clinical (TC) is defined as a traditional faculty lead (8:1) 126-hour clinical (mental health) spanning 10 weeks. This is followed by a 126-hour randomly assigned precepted clinical spanning 4 weeks (one preceptor at one site).
- Immersion Clinical (IC) is defined as a precepted 252-hour clinical spanning 14 weeks (one preceptor at one site). Students obtain 126 hours in the first 10 weeks and 126 hours in the last 4 weeks.
Based on site availability, students are interviewed and selected by agency representatives for IC opportunities within various organizations. The coordination of interviews and placements are time intensive and facilitated by a faculty member and a clinical placement coordinator, each receiving release time. Students not selected by an agency, or those choosing not to interview for IC, are placed into the TC option. To highlight the difference between the two options, students in the TC are subjected to two rotations, with one faculty for 10 weeks followed by a shift to a different site with one assigned preceptor for 4 weeks. The IC students are locked into a single site, single preceptor model for the entire semester (14 weeks). The total hours (252) required over 14 weeks remains constant.
To measure differences in Gen Z learners in a TC versus an IC, we used the Readiness to Practice Survey (CFRPS; Casey et al., 2011) and the Nursing Anxiety and Self-Confidence With Clinical Decision Making Scale (NASC-CDM) (White, 2014). Permissions were obtained for use of the survey and scale. The CFRPS is a three-part, self-reported survey including (a) a collection of demographic and descriptive elements, (b) a 4-point Likert scale (1 = strongly agree, 2 = disagree, 3 = agree, 4 = strongly agree) with the following domains of readiness: clinical problem solving (α = .80), professional identity (α = .65), trials and tribulations (α = .63), and learning techniques (α = .50); and (c) two open-ended questions regarding entry to practice and reasons for choosing nursing. Reliability of the 20-item survey has been reported as having a Cronbach's alpha of .69 overall for the 20-item comfort/confidence survey (Casey et al., 2011). In the current study, the Cronbach's alpha is .75. Content validity of the CFRPS was determined by a panel of expert clinical faculty (Casey et al., 2011).
The second self-reported instrument (NASC-CDM) by White (2014) measures perceptions of self-confidence and anxiety during clinical decision making and includes 27 items on a 6-point Likert scale (1 = not at all, 2 = just a little, 3 = somewhat, 4 = mostly, 5 = almost totally, 6 = totally). Cronbach's alpha reliability indicates the NASC-CDM self-confidence subscale, where α =.98 and the NASC-CDM anxiety subscale α = .97 (White, 2014). The NASC-CDM Cronbach's alpha for the current study is .97 for anxiety and .97 for self-confidence. Construct and convergent validity are described and reported elsewhere (White, 2014). The author describes no norming or cut scores. All analyses were conducted with SPSS® version 17.0.
The majority (n = 32, 70%) of participants in this study completed 252 hours in a precepted immersion clinical in acute settings (medical–surgical, n = 21, 65%; women and children, n = 8, 25%). In total, mean scores on the CFRPS comfort/confidence subscales indicate that in general participants agreed that they are ready to problem solve (n = 46, M = 3.04, SD = 0.40), agreed to a lesser extent that learning via simulation and journaling prepared them for practice (n = 46, M = 2.93, SD = 0.44), and were not comfortable addressing trials and tribulations (n = 46, M = 2.3, SD = 0.40). Participants agreed that they had comfort and confidence in assuming components of the professional role (n = 46, M = 3.4, SD = 0.39).
Scores on the NASC-CDM indicate that participants were mostly self-confident (n = 46, M = 4.0, SD = 0.77) and only slightly anxious (n = 46, M = 2.84, SD = 0.88).
An independent samples t test (two-tailed) was performed to compare scores on readiness for practice and anxiety/self-confidence during decision making (CFRPS) between groups and found no statistically significant differences in the following domains: clinical problem solving (traditional, M = 3.02, SD = 0.39; immersive, M = 3.07, SD = .43; t (44) = 0.40, p = .68), professional identity (traditional, M = 3.45, SD = 0.33; immersive, M = 3.36, SD = .46; t  = 0.68, p = .49), trials and tribulations (traditional, M = 2.33, SD = 0.39; immersive, M = 2.38, SD = 0.42; t  = 0.35, p = .72) and learning techniques (traditional, M = 2.96, SD = 0.36, immersive, M = 2.90, SD = 0.53; t  = −0.37, p = .71), and found no statistical difference between groups. Similarly, there was no statistically significant difference in NASC-CDM scores—self-confidence (traditional, M = 3.96, SD = 0.89; immersive, M = 4.07, SD = 0.66; t  = 0.48, p = .63), and anxiety during clinical decision making (traditional, M = 2.82, SD = 0.88; immersive, M = 2.86, SD = 0.71; t  = 0.16, p = .89). There was only a slight difference in the skills each group was uncomfortable performing, with immersion students listing chest tube first and assessing a patient with a change of condition second. Traditional students listed change in condition first and central line care second.
Results from this pilot study comparing readiness for practice and anxiety and self-confidence during decision making between Gen Z students completing a traditional verse immersion clinical indicate no differences between the groups. These are similar to the findings of Kumm, Godfrey, Richards, Hulen, and Ray (2016), who also found no significant differences when examining preceptors' perceptions of student performance between an 8- and 16-week immersion experience. Similarly, Ownby, Schumann, Dune, and Kohne (2012) found no longitudinal difference on multiple measures (e.g., grades, examinations, clinical paperwork, and evaluations) when examining differences between traditional and precepted students. To date, it is believed that longer and more intensive precepted clinical experiences provide opportunities for students to hone critical judgment and critical thinking skills. Our findings suggest that in this generational cohort, who have shorter attention spans, that immersive experiences are no more beneficial than traditional ones (Chicca & Shellenbarger, 2018). As previously described, this generational cohort craves interpersonal hands-on learning opportunities—however, being assigned to a single preceptor did not affect readiness, self-confidence, or anxiety.
What should be recognized is that the availability of IC sites and preceptors is fluid and varies between semesters, requiring shifting workloads and variability in the numbers of alternative clinical sites needed to meet program objectives. There is a greater expenditure of resources when securing health care agencies, selecting experienced preceptors, and interviewing and placing students for IC experiences when there may be no perceivable differences in transition experiences including readiness, anxiety, and self confidence in Gen Z students. Health care partners are interested in hiring practice-ready graduate nurses without understanding the complex factors impacting transitions (Duchscher, 2009; Hoare, 2016) or the influence a seasoned preceptor may have on new nurses (Clipper & Cherry, 2015). Faculty and hospital placement coordinators should recognize that immersive experiences over longer periods of time for students may increase preceptor fatigue and burnout especially in light of the learning needs previously discussed (underdevelopment of social and oral communication skills, shorter attention spans, and a tendency toward boredom (Chicca & Shellenbarger, 2018).
Despite the number of hours spent in the clinical setting or method of delivery, it appears that Gen Z graduating nurses exhibited no difference between readiness to practice, self-confidence, or anxiety in this pilot study. For this reason, faculty planning, organizing, and implementing changes to traditional clinical teaching models should consider measuring outcomes before and after changes are instituted and critically examine differences in this generational cohort. If program faculty are moving toward capstone or immersive experiences as a clinical learning strategy, hospital leadership should collaborate with faculty to ensure adequate support is provided to preceptors to avoid burnout (Bodine, 2018).
Findings from this pilot study must be viewed with caution, as the sample size was small, homogenous, predominantly female, and drawn from one university located in the Midwest. The tool and survey used are self-reported and administered only one time. Poor response rate could be due to timing of data collection. Students who were 1 day away from graduation may have already disengaged from the academic setting. The average age of respondents in the original study (Casey et al., 2011) was 29 years, and the survey was published in 2011. The original sample was likely comprised of participants born in the early 1980s. This underscores the need to ensure constructs and psychometric properties of surveys and tools are tested and refined as student demographics shift.
Academicians and health care partners must realize and consider the unique learning and transition needs of Gen Z students, as they are soon to become the future of nursing and the work-force. Similarly, we should strive to better blend learning pedagogies understanding how Gen Z students integrate technology into their learning environment to boost communication skills and improve self-confidence and readiness to practice.
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