1. Vahey, Doris C. PhD, RN

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"You can't see the forest for the trees" aptly describes those recent nursing graduates who choose to specialize instead of honing their skills on a general medical-surgical unit. In my opinion, all graduate nurses (GNs) should be required to spend at least 1 year on a general medical-surgical unit before moving into a specialty area. This is especially important during the current nursing shortage, which has led to new nursing recruitment strategies and educational programs. Compelling the GN to train on a medical-surgical unit will ensure a minimum standard of care, ease the transition from school to the clinical setting, and cement the foundations of nursing practice.


For decades, the nursing profession has struggled with an appropriate minimum level of education for entry into practice. Burdened with another critical nursing shortage, nursing education has devised several new strategies to facilitate recruitment into nursing programs as well as increase graduation rates, including "fast track" programs that enroll candidates with diverse educational experiences and allow them to become registered nurses in as little as 12 months. Especially because nursing has multiple methods of entry, a mandatory year of medical-surgical nursing experience for all GNs can act as an equalizer, ensuring a minimum standard of care and professional practice.


Medical-surgical units expose the GN to a variety of patient care experiences, affording the GN the opportunity to see how fundamentals can be integrated into care for the whole patient, and how these fundamentals of practice can be transferred to other patients. This is an extremely valuable lesson, since shortages increase the possibility that nurses will have to "float" to other units. Working on a general medical-surgical unit also forces the GN to think outside the immediate healthcare environment and consider the broader environment from which patients have entered the system (e.g., home, street, extended care facility), as well as to plan for discharge. This skill enhances patient care quality, safety, and satisfaction. Specializing immediately after graduation encourages a focus on a specific subset or subsystem of patient care (e.g., orthopedics), limiting the GN's ability to integrate knowledge required to care for the whole patient. Specialization requires the acquisition of an entirely new skill set (e.g., the use of technologies in critical care or fetal monitoring in Labor and Delivery), which can undermine the GN's development toward becoming an expert practitioner.


According to Benner (1984), nursing students are considered novices and become advanced beginners as they transition into the professional practice arena. It takes several years for a GN to advance to competent, proficient, and then finally an expert nurse. As advanced beginners, GNs are motivated by anxiety and feel unsure about what they know. Their focus is on organizing and prioritizing their environment and patient care, and they work best with clear-cut policies and procedures. Introducing too many new concepts, as would happen in specialty areas, can be detrimental to their ability to gain confidence and to ultimately advance toward becoming an expert nurse.


Graduate nurses who forego experience on a general medical-surgical unit and enter directly into a specialty area can focus too much on the details of learning the specialty and miss the opportunity to see the whole patient care experience, not only from an anatomy and physiology standpoint, but from a healthcare systems point of view as well. While GNs are often drawn to the excitement of specialty areas (and there are shortages in those areas as well), nursing leadership (e.g., educators, recruiters, and managers) does them a disservice by directing them to specialties. Healthcare facilities and patients require nurses who are flexible, well-trained, critical thinkers. Spending 1 year on a medical-surgical unit is an excellent way for the GN to bridge nursing education with nursing practice, and to prepare for the turbulent, ever-changing healthcare environment. The experience gained on a general medical-surgical unit builds an invaluable foundation for future practice with skills that can easily be transported to all other patient care settings.




Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing. Menlo Park, CA: Addison-Wesley. [Context Link]