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Objective: The future of nursing depends on newly licensed RNs (NLRNs), who often need help in transitioning from an academic to a clinical setting. This study sought to describe the NLRN's orientation experience and to identify ways of enhancing it.
Methods: Using qualitative methods, a convenience sample of NLRNs was recruited and 21 were interviewed; audio recordings of the interviews were transcribed and validated for accuracy. Interpretative analysis of the transcripts sought to identify major patterns and themes.
Results: Four patterns and 10 themes emerged from the data analysis: preceptor variability (with themes of satisfactory and unsatisfactory preceptorship), professional growth and confidence changing with time (with themes of learning through experience, learning to manage time, and learning to communicate), a sense of being nurtured (with themes of support through the program, the preceptor, and peers), and enhancing the transition (with themes of orientation enhancements and human resource enhancements).
Conclusions: These qualitative findings provide insight into the NLRN's transition from student to professional and suggest ways institutions might enhance orientation. Further study is warranted.
Despite slow, continued growth in the U.S. economy in general and in the health care industry in particular, nursing shortages are predicted to persist over the next two decades. The turnover rate for bedside nurses was 11% in 2012, a rate that increased to 13% in a January 2013 survey.1 That same survey found that nearly half of U.S. hospitals reported RN vacancy rates of less than 5%; a third of hospitals reported vacancy rates between 5% and 9.9%, and 18% reported vacancy rates of 10% and higher.1 Buerhaus and colleagues projected in 2009 that although a higher-than-expected number of new nurses were entering the workforce, by 2025 the U.S. nursing shortage would reach 260,000 nurses.2 With the average age of RNs nearly 45 years, 10-to-15-year projections estimate that 1 million nurses over age 50 will reach retirement age.3
In an effort to improve nurse staffing, hospitals have actively recruited newly licensed RNs (NLRNs). Consequently, first-year turnover rates for new nurses remain relatively high, ranging from 17% to 22%.4, 5 High RN turnover rates and reduced RN staffing have been linked to increased rates of hospital-related mortality, hospital-acquired pneumonia, hospital-associated falls and pressure ulcers, medication errors, hospital-acquired urinary tract infections, and readmissions.6-12 Jones reported that the costs in 2007 associated with RN turnover were an estimated $88,000 per new nurse and $82,000 per experienced nurse.13 In light of these costs and the nursing shortage, organizations must better understand the NLRN's transition from student to professional in order to increase rates of retention.
Our interest in NLRNs began early in our careers. We realized, through our own experience as new nurses and as preceptors, that nursing orientation does not give NLRNs the skills they need to make the shift from student to professional. Three of us (LS, LP, DJ) developed an extensive orientation program for NLRNs. One of us (BB) focused her doctoral work on the retention of NLRNs and the impact that orientation had on nurse retention.14 Two of us (KM, PLH) implemented a residency program for NLRNs at an integrated health care organization; one (PLH) furthered her interest in the NLRN's transition to practice as a faculty member of an academic institution, and the other (KM) focused on understanding experiences of the NLRN's first year of practice.15 Finally, one of us (FM), who worked as a bedside nurse for over 30 years, had a long history of mentoring and precepting NLRNs. And recently, three of us (LS, PLH, FM) conducted a study investigating the experience of the older bedside nurse and the transition to retirement,16 which sparked our interest in the NLRN's transition to practice and the role older nurses play in that transition.
The first few months of employment is a crucial time in a nurse's career.17 According to Benner's novice-to-expert model, RNs enter the profession at the novice or advanced-beginner level18 and thus are at an early stage of applying clinical skill and reasoning. Hospital orientation programs help to ease the shift from novice to advanced beginner. But these programs vary in content and intensity, length and structure, and in their use of preceptors and mentors during an internship or residency program.17 Scott and colleagues found that NLRNs who had a long orientation were more satisfied with their current job.17
We conducted a literature search using PubMed, Ovid, and EBSCOhost databases for studies conducted from 2004 to 2013. Search terms included new graduate nurse, acute care hospital, transition, turnover, retention, qualitative, orientation, and preceptor. The search strategy identified and retained published studies written in English.
Our literature review revealed several well-recognized challenges NLRNs face in the transition to practice, including job stress, lack of knowledge and confidence, heavy workloads, too little support, inadequate skills in time management and critical thinking, and interprofessional conflict.14, 19-25 Casey and colleagues reported in 2004 that a majority of NLRNs entering the workforce did not possess the confidence and competence to assume accountability for patient safety.20 And the gap between theory and practice persists: in 2008, Burns and Poster identified a gap between the knowledge and skills students acquire and those needed in clinical settings,26 and a 2010 report by Benner and colleagues explains that many nursing students enter the profession unprepared to act as practitioners.27
But a preceptor can provide NLRNs the link between academics and clinical practice.28 Preceptor programs can increase NLRNs' job satisfaction, augment their acquisition of skill and knowledge, enhance their confidence, smooth role transition and socialization, and increase retention rates.20, 29-35 Additionally, nurse residency programs have been an effective strategy deployed by health care organizations to assist with NLRN transition to practice. Positive outcomes from these programs include improved self-confidence, satisfaction, and retention.24, 36
We sought to describe the orientation experience of NLRNs at one hospital in the southeastern United States. For this study, we defined the term NLRN as an RN licensed for no more than 12 months. We used grounded theory methodology as described by Glaser and Strauss to explore the experience of NLRNs.37 The research questions guiding us were:
* What is the orientation experience of NLRNs who have completed the hospital's orientation program?
* What would enhance the NLRNs' orientation experience?
The acute care hospital where we conducted this study provides an extensive orientation program for NLRNs. It consists of a nurse residency program, an onsite "pipeline development team," and a preceptorship. The year-long nurse residency program was developed by the University HealthSystem Consortium; NLRNs are placed into cohorts based on hire date and attend monthly educational sessions on the transition to professional nursing. The onsite pipeline development team consists of a nurse manager and a clinical nurse specialist who monitor the NLRNs' orientation. The NLRNs report directly to the team during the orientation period. (Table 1 outlines the responsibilities of that team.) The preceptorship involves assigning an NLRN to an experienced RN during the unit orientation. The preceptor provides clinical supervision and support.
Sample. This study was conducted between October 2010 and February 2012. We chose a convenience sample of NLRNs who had completed the hospital's orientation program and were willing to participate in an audiotaped interview. We had a potential recruitment pool of 63 NLRNs.
Prior to data collection, we obtained approval from the organization's nursing research committee and institutional review board. The chief nursing officer gave NLRNs a recruitment flyer during the last formal class of orientation at the hospital; if interested in participating in the study, the NLRNs contacted one of the researchers to schedule an interview. Ten NLRNs responded and were interviewed. A flyer was then e-mailed to the pool of NLRNs; 11 responded and were interviewed. Two NLRNs were excluded: one was fired by the hospital and the other provided no contact information.
Data collection and analysis took place simultaneously. Interviews took place in person or by telephone between 7 am and 7 pm, Monday through Friday, during the nurse's work shift, and lasted from 30 minutes to one hour. All interviews were audiotaped and transcribed.
Three of us (LS, FM, SGM) conducted unstructured, one-to-one interviews. We asked two open-ended questions: "Tell me about your orientation experience," and "Tell me about factors that would improve or enhance the orientation experience." We continued the interviews until we determined that data saturation had occurred with 21 interviews.
Tape-recorded interviews were transcribed verbatim, and we used the constant-comparative method to analyze transcripts.38, 39 Data were analyzed by hand using all research team members. A written summary that included keywords and phrases from each interview was prepared to explore relationships and common meanings within the nurses' stories. Interpretations were discussed among the researchers. Each sentence of the transcripts was coded using the NLRN's words. Microsoft Word 2010 was used to format, code, and sort the data from the interview text. A codebook was created to list the definition of each code. The coded data were reread to ensure codes and definitions were similar. If differences existed, data were recoded or additional codes and definitions were created. Codes were clustered into categories and themes. Subsequent interviews further validated the emerging themes and continued until no new data emerged. Categories and themes were examined for common meanings to identify similar patterns. The researchers conducted member checks with the NLRNs to verify study findings. Additionally, those of us conducting the interviews kept a journal in which we described the interview settings and participants' nonverbal communication. For example, if we noted a participant crying, we noted this information and at a later time referenced these notes when reviewing the transcripts. We did not conduct statistical or analytical analysis on any of our observations because of the small amount of data collected. We maintained an audit trail so that other researchers can follow our procedures for future studies.39
The sample included 21 NLRNs, 20 women and one man, working in the 633-bed, acute care hospital (see Table 2). The sample's demographics represented those of the hospital's overall nursing population in terms of sex, age, race, nursing degree, and health care experience.
Four patterns emerged from the analysis (a pattern is a common meaning that was identified in all 21 interviews). Ten themes emerged from the four patterns (a theme is a common relationship that brought meaning to each pattern).
Preceptor variability, the first pattern that emerged, had two themes, showing that preceptors enhanced or hindered NLRNs' progression.
Satisfactory preceptorship. Many NLRNs described their preceptors as knowledgeable, experienced, helpful, personable, and informative. Other positive attributes included having the ability to teach, a desire to assist the NLRN, good communication skills, a nurturing attitude, and the ability to give feedback on job performance. As one NLRN expressed it:
"My preceptor is knowledgeable, experienced, patient[horizontal ellipsis] [an] excellent teacher, key to my success, and trusting. I could communicate with her and did not feel threatened. I was able to ask questions, and did not have to worry about making a mistake and being yelled at."
Many NLRNs said that the preceptor was critical in building their confidence and preparing them to practice independently. Being corrected in a nonjudgmental way was appreciated, as one NLRN said: "My preceptor was the best part of it and she acted like a shield moving me through the orientation. She always presented corrective action in an educational way and an opportunity to learn." Another NLRN said her preceptor helped her become more independent over time:
"If I made a mistake, I was able to learn from the mistake. I was not afraid to ask questions. She would let me make my own decisions and would double check things for me[horizontal ellipsis]. In the beginning I needed help, approval, supervision, but by the end I was on my own."
Unsatisfactory preceptorship. Some NLRNs described their preceptors as inconsistent or too inexperienced. One nurse was "miserable," she said:
"I had a preceptor who was very conflicting with my personality and it was her first time precepting. Every time I came to work it was chaotic and I had no idea what to do. She started asking questions and I started crying. I would have left [the hospital] if I had not left that unit. Everything that could have went wrong, went wrong."
Several nurses described being nervous about communicating with a preceptor. One NLRN said:
"I was scared of telling my preceptor anything. She wanted me to answer with "Yes, ma'am" and would say my questions were stupid. I felt like I had to get things always right and it made me nervous. She would tell me in front of patients and others that I was not doing something right."
Other NLRNs said their preceptors corrected them in an inappropriate way. One described what happened after she learned how to remove a drainage tube from another nurse on the unit:
"Apparently, the nurse did it differently than my preceptor, and in front of the family, my preceptor said, "Oh you're not going to do this," and I responded, "This is how the nurse showed me." While correction is necessary, she could have done it in a different way."
Several NLRNs said they were expected to practice independently, with little supervision or guidance. As one NLRN said:
"My preceptor told me that I did not listen to her and was defensive. There was a meeting called and I had a rebuttal for almost all examples. I felt blasted that day and that it came out of nowhere. I do wish I had the feedback because I did not know that they thought I was putting patients in danger[horizontal ellipsis]. For weeks, my preceptor was letting me practice independently and all of a sudden, I was doing everything wrong. She wanted a day or two to watch me because she had not been watching me enough before. I had to ask my preceptor to stay with me. Two days later, she said I could return to being independent. After the meeting, I did not understand why my preceptor let me be so independent."
Professional growth and confidence changed with time. This second pattern included three themes.
Learning through experience. NLRNs recollected stories of immersing themselves in the learning process with the aim of attaining the knowledge, confidence, and skills to practice independently. In the beginning, several NLRNs said, they lacked the competence and the confidence to make sound clinical judgments and respond appropriately. One said, "You have to go on your instinct because you're not 100% confident in your assessment skills. In the beginning, I was nervous when I first came off orientation. However, now I feel much more confident in doing things." And a step-down NLRN described her uncertainty in responding to a vital-sign alarm:
"The patient's blood pressure dropped to 80 systolic. When I went into the room, the patient was up talking. My preceptor told me that when the alarm goes off and the blood pressure is going down you don't have to focus on the blood pressure. You focus on the whole, entire picture-the respiratory, the oxygen, all that stuff-because sometimes the blood pressure cuff is in the wrong position."
Another NLRN was attempting to practice independently without notifying the proper chain of command when a critically ill patient's blood pressure dropped-only to discover later that she wasn't authorized to act as she did.
"[My preceptor] wasn't there when this happened and I didn't try to find her. I didn't call rapid response or alert anyone else. They felt like I went about it the wrong way. I shouldn't have left the room. I should have called the charge nurse. I had never heard those steps before[horizontal ellipsis]. I didn't really know how severely wrong I was doing things."
Learning to manage time. NLRNs spoke about time management and how they learned to improve it. One said she was able to improve her charting time by slightly changing her routine:
"Up until my last month, I would always get behind in my charting. I started charting during the patient's assessment in the room. Now I'm done in time."
Learning to communicate. Calling a physician was frequently cited as a stressor for the NLRN. As one participant said:
"I had a perception of how nasty calling a physician can be. One of my goals was to make more physician phone calls. My preceptor and I would run through how to communicate with the physician. I tried to stick to the SBAR [situation-background-assessment-recommendation]. Calling a physician was not as bad as I was expecting. My first one was really nice and that was relieving."
A sense of being nurtured. For this third pattern, three themes emerged.
Program support. NLRNs commented favorably on the orientation program and most said they felt welcomed and supported. The orientation program staff, preceptors, unit peers, and other new graduates provided support by answering questions, providing encouragement, and giving feedback. The onsite pipeline development team served in an advisory role for the NLRNs, in addition to their preceptors.
"[The onsite pipeline development nurses] have been fantastic and supportive in everything[horizontal ellipsis]. I never felt alone. I always knew how I was doing."
Preceptor support. Most of the preceptors provided a nurturing and supportive environment that increased the NLRNs' confidence and further amplified their clinical skills. One NLRN who had the same preceptor throughout orientation said that she felt prepared to work independently and that she was "always honest and upfront" with her preceptor.
After orientation, the preceptor's support in some cases evolved into an ongoing mentorship and a friendship. One NLRN said, "She will call, text, and check on me. She stays in contact with me. If I have a problem, I still call her."
Unit and peer support. NLRNs reported that work environments were supportive. The nurturing staff and practice environment helped alleviate the NLRNs' apprehension in transitioning from orientation to independent practice. "Once off orientation," one NLRN said, "I was not as nervous because I have support around me. If someone is busy, I go into the ICU and they help me since our unit is so small." Another NLRN said:
"The unit is a very motherly and friendly place. They are always asking if I am okay or if I need help. Having staff show me a task, hands on, and then allowing me to do it the next time played a big part in the feelings of comfort I have with nursing."
Enhancements needed to improve the orientation experience. The fourth pattern to emerge involved what was needed to improve the orientation experience. NLRNs provided several ideas that we sorted into two themes.
Orientation program enhancements. Many NLRNs said that the organization's residency, onsite pipeline development, and preceptorship programs could be improved. Suggestions included adding classes on charting and policies and procedures; decreasing redundant orientation for NLRNs who had been employed previously by the hospital; and restructuring the time spent in the fellowship and residency classes. As one NLRN said, "The residency classes are spread out and could have been two hours. There is a need for charting classes to know what you're supposed to absolutely chart." Another NLRN said that the residency program could be covered through computer-based learning modules to allow for more autonomy. That nurse also said, "Some stuff that they talked about six months into my employment should have been addressed in the beginning, things like medication errors and how to report a near miss."
Human resource enhancements suggested include developing preceptors, giving more consistent feedback on performance, maintaining a consistent location for unit orientation, providing standards for learning institutional policies, and implementing a mentoring program. Of preceptor development, one NLRN advocated the use of formal guidelines for preceptors on how much time they spend working with NLRNs and what tasks the NLRN can perform independently. That nurse also said, "I did not realize my preceptor was uncomfortable until all the things came up at our meeting." Another NLRN, who had a first-time preceptor, suggested a training program was needed:
"We were discovering things together but it was a good experience. Also it would be beneficial to have preceptors that really want to be a preceptor, know what is expected of them, and know about PBDS [the performance-based development system]."
NLRNs wanted more consistent and timely feedback from the preceptor, as one explained: "My preceptor was talking to everyone but me. I never felt that I received the feedback. My preceptor would evaluate me each week but I don't know what she said[horizontal ellipsis]. I was not able to judge how I was doing." Several of the NLRNs interviewed were not directly involved in their performance appraisal, as one participant described:
"I was used to making As in school and excelling; however, I received 2s and 3s on my evaluation. These were mediocre ratings compared to their scale and this was very disappointing. Performance goals were never clear to me. I do not know what I am being judged on."
One NLRN who went through orientation on more than one unit said that on the first unit "physicians and physician assistants knew the nurses by name." But on another unit "morale was much lower. Having to change units was very frustrating." Several of the NLRNs felt that a mentorship program was needed after orientation. One said that having a mentor with an "open-door policy" would be ideal for new nurses.
In our interviews, NLRNs discussed orientation as both an ending and a beginning. And they viewed preceptorship as critical to their transition from an academic to a clinical setting. This finding is consistent with those of other studies.21, 40 Also, NLRNs often view having a preceptor as important to their development of skills that prepare them to practice independently.21 Several studies have found that when preceptors provided support, guidance, timely feedback, supervised training, and continued mentorship, NLRNs report a more positive transition to clinical practice.21, 22, 41 We found that when NLRNs said that their preceptors did not have these characteristics, their perceptions were less positive and their progress was delayed-a finding supported by other researchers.22, 41, 42
We found that several NLRNs were corrected in a punitive manner in front of peers, patients, and families; were not provided or given consistent feedback; were expected to practice independently; and exhibited emotional exhaustion. These findings are comparable to those reported in other studies.21, 22, 41, 42
In our interviews, NLRNs reported having minimal knowledge, confidence, or skills in clinical decision-making, time management, and communication when they started the orientation. They said that performing a task repeatedly was how they learned and felt they needed more practice while in nursing school. These findings are similar to those in studies that have reported the "transition shock" NLRNs go through at the start of orientation.25, 43 With time, the NLRNs we interviewed said, they grew professionally, acquired new skills, and made a successful transition to practice. They also expressed feeling frustrated and insecure in performing their professional duties. Assisting NLRNs in the socialization process (through preceptorship and residency programs, for example) has been shown to lead to NLRNs' stronger commitment to the organization, decreased stress levels, and increased retention levels.30, 36, 44-47
The NLRNs we interviewed suggested several improvements to the orientation offered. They valued hands-on clinical experiences but did not always see the value in classroom time in the residency program. Several of their other suggestions have been shown to be effective in previous research: creating preceptor-development programs,48-50 having a standardized approach for learning institutional policies,31 and offering a mentorship program.51, 52
Previous research supports both the need for nursing residency programs and the positive outcomes they can achieve.24, 36, 45-47, 53 Our study supports the need for better coordination between the hospital's residency program and preceptorship activities; the NLRNs reported a disconnect between these aspects of orientation. Certain hospital policies and procedures were presented late in the residency program, NLRNs reported; exposure to all policies early in the residency program would help to prepare the NLRN to derail a potentially serious safety event.
Limitations. Our findings should not be generalized because NLRNs' experiences and perceptions change over time. Also, we conducted the interviews with a mostly white sample in only one U.S. hospital. A comparable study with a more diverse sample in terms of sex, race, ethnicity, and geography would be appropriate.
Besides strengthening the preceptor role and developing mentorship programs, we suggest that using simulation and partnering with academic institutions holds much potential for hospitals.
A strong preceptor relationship is critical to an NLRN's role socialization, support, and professional development, and certain strategies may help to improve the experience. Lee and colleagues created a preceptor program delineating preceptor obligations and responsibilities to orient new nurses. Program outcomes included a reduction in turnover, costs, adverse events, and falls and improved nurse satisfaction.54 Our findings suggest that fortifying the preceptor's development and finding ways to match preceptors and NLRNs could be a good investment.
Preceptor training workshops have been shown to help prepare experienced nurses to act as preceptors, boosting the preceptor's confidence and competence in coaching and giving feedback, resulting in improved retention rates for new nurses.55 Several researchers have identified topic areas that should be incorporated into preceptor development programs, including encouraging experiential learning, giving constructive feedback, assessing competency, managing time, and strengthening organizational skills.48, 49 In addition, little is known about how effective preceptor-recognition programs are in retaining nurses. Dillon and colleagues developed a preceptor-recognition event that included food, a speaker, certificates, and prizes.56 Preceptors expressed appreciation for the recognition. And Biggs and Schriner discussed the development of a preceptor recognition program at a children's hospital that included a certificate of appreciation, online educational support, and a newsletter.57
Partnerships with academic institutions may help to build on the limited amount of clinical experience NLRNs received in school. Using different strategies for new nurses' development in addition to the orientation process may help to improve NLRNs' skills in a safe, supported environment. For instance, dedicated education units (DEU) are partnerships between hospitals and nursing schools that seek to ease the transition of clinically experienced nurse graduates into the practice setting at a lower cost with improved satisfaction.58, 59
Simulation use may provide an opportunity for experiential learning for NLRNs. Simulation has been shown to be an effective teaching strategy in a supportive and safe atmosphere60 and can enhance competence and confidence.61, 62 Simulation may also ease performance anxiety in a "controlled chaos" environment.60
A mentorship program or a buddy program can help to provide NLRNs with support beyond the formal orientation period.63-65 Formal and informal use of mentors may help to decrease the stress during the separation period from the orientation staff.
In conclusion, hearing the voices of NLRNs at one institution gave us insight into what would help to ease their transition to clinical practice. They spoke of the importance of having competent, knowledgeable preceptors to guide and support them, extensive hands-on clinical experiences to hone their skills, nurturing support within their organization, and a redesigned residency program. We urge health care organizations to listen to the needs of their NLRNs, who have much to say about how to tailor orientation programs for their success.
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