1. Herleth, Anne MSW, MPH
  2. Virkstis, Katherine ND
  3. Renfroe, Julia BA
  4. Rewers, Lauren BA


Despite increased onboarding and training for new graduate RNs, it is taking longer for nurses to develop clinical competence in today's complex care environment. At the same time, hospitals and health systems are facing a shortage of experienced nurses. If left unaddressed, patient quality and safety could be at risk.


Article Content

This is the 2nd article of a series. The 1st article of this series, The Experience-Complexity Gap, in the December 2019 issue (volume 49, issue 12) of The Journal of Nursing Administration (JONA), the authors explain that there is a shortage of nursing experience that will continue to grow in the coming years as more baby boomer nurses retire. At the same time, the care nurses must deliver is more complex. The authors developed a name for this emerging workforce challenge: the experience-complexity gap. In this article, the authors explore why the experience-complexity gap makes it harder for new graduate RNs to be clinically competent and suggest two strategies for addressing it.


The Challenging Road to Clinical Competence for New Graduate RNs

The transition to practice is a challenging time for many new graduate RNs.1 But the emerging experience-complexity gap may be making this transition more challenging. Many nursing leaders observed that it is taking longer for new graduate nurses to develop clinical competence than previous generations.2


In response, many hospital and health systems are investing more resources to help new graduate RNs transition to practice. Additional interventions include longer orientations; more simulation laboratories, competency checklists, and online learning modules; and new nurse residency or mentorship programs. Combined, these additional supports require considerable time and financial investment-an average of 137 nonproductive hours to onboard 1 RN.3


There is a wide body of evidence supporting the effectiveness of these interventions on nurse retention and confidence.4-6 Yet, Advisory Board researchers found limited evidence on the impact of these interventions on clinical competence. Anecdotally, researchers found that the growing number of competencies and skills that new graduate RNs must learn during their onboarding period is often overwhelming, which may further explain the slower progression from clinically "novice" to "competent."7


Strategies to Teach Novice Nurses More Effectively

To make further progress on the transition from novice to competent, hospital and health system leaders need to redesign current onboarding and training for new RNs. There are 2 strategies to do this.


The 1st strategy is to scope weeks 1 to 12 of onboarding for new RNs. Rather than adding more competencies and skills, nursing leaders should streamline the list to those most foundational to nursing practice, creating more time for repeated practice providing the same type of care before moving on to more variable situations.8 For example, an acute care hospital in Indiana created targeted skills intensive for new-to-practice RNs. The intensive is a multiday, unit-based orientation in which a cohort of 3 to 5 new graduate RNs practice select clinical skills and competencies under the direct supervision of a dedicate preceptor.7


The intensive focuses on 6 nursing competencies, such as central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection, and patient safety. These competencies are consistent across the health system, but unit managers can add select competencies to their intensive based on specialty. For example, the ICU added electrocardiogram interpretation. Each day, the cohort of new graduate RNs and the preceptor spend 8 hours practicing the skills related to 1 of the competencies. This work is offloaded from unit staff. For example, CLABSI day includes the following: CLABSI rounds, central line dressing changes, IV infusion pump, blood draws, IV start, IV priming and tubing changes, and documentation of completed tasks. From 2017 to 2018, 700 new graduate RNs were onboarded through the intensive. During the same time, the number of orientation extensions decreased, as did the number of harm events despite the influx of novice nurses.7


The 2nd strategy to maximize the effectiveness of new graduate RN support is to standardize preceptor work. Preceptors play a critical role in nursing clinical education. Yet, there is wide variation in the way preceptors teach standards, with 24% of new nurses reporting seeing preceptors contradict best practice.9 As a result, it is harder for novice nurses to learn standards correctly, which can delay their progression to being clinically competent.10


Some organizations have updated their preceptor program to account for this variation in preceptor teaching, as well as preceptor burnout due to the influx of new graduates in the nursing workforce. For example, a pediatric hospital in Canada updated their preceptor program in 2 ways: in-depth training and establishing ongoing preceptor support.8


The introductory preceptor training is a multidisciplinary workshop on how to develop critical thinking among new graduate clinicians. Sample skills covered include teaching diverse learners, clinical questioning, and delivering actionable feedback. Before attending the workshop, clinicians are required to read a toolkit detailing the preceptor's role expectations, timelines, and introductory concepts. This frees up time during the session for more role-playing activities. Preceptors are required to complete this training prior to taking on a preceptee.8


Ongoing support for preceptors takes multiple forms, including optional advanced training sessions on specific topics, peer mentorships, and educator-preceptor check-ins. These supports help preceptors troubleshoot challenging teaching moments and get feedback on their own skills. By updating the preceptor program, preceptors are more effective and satisfied in their role, which helps them more effectively teach new graduate RNs.8



Given that the experience-complexity gap is expected to widen as more experienced nurses retire, it is important for nurse leaders to consider how current onboarding practices help or hinder new graduate RNs as they develop clinical competence. In addition to the 2 practices detailed in this article, Advisory Board researchers identified several other strategies and preceptor models to address this challenge.


For more information, JONA readers can request a copy of the Advisory Board's publication, The Experience-Complexity Gap.




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