1. Lund, Patricia Z. EdD, RN

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There is no evidence to support or refute the premise that new graduates should work in medical-surgical nursing prior to working in a specialty area. There is ample evidence, however, of nursing dissatisfaction, burnout, and high turnover rates in the workplace. Aiken et al. (2001) reported 40% of nurses being dissatisfied with their jobs, with one in three nurses under age 30 planning to leave their jobs within a year. With these facts in mind, in my opinion, now is the time to make bold choices about new nurses, to offer new graduates the opportunity to start their careers in their areas of choice, to support them with thorough orientation programs, and to demonstrate the quality nursing leadership needed to attract them to our facilities.


Today's nursing graduate brings not only new knowledge, but also an assortment of skills to the workplace. Some have English as a second language; all have modest to strong computer skills. For many, nursing is a second career, or a career that is beginning after years spent raising children and managing a household. Almost all work while in school; summer externships are sought, and multitasking is second nature to them. They average 30 years old at graduation, joining a profession where the average age of the working nurse was 43.3 in 2000, and where 40% are expected to exceed 50 years of age by 2010 (General Accounting Office, 2001).


Nursing is changing dramatically. We have fewer graduates, but enrollments are currently on the rise (a result of increased media and government attention and recruitment efforts such as Johnson & Johnson's Dare to Care and the Discover Nursing campaigns started in 2002). More than 1 million new and replacement nurses will be needed by 2012 (American Association of Critical Care Nurses, 2004). Second career students often come to nursing with specific practice areas in mind, many times determined by life experiences. Those graduates are likely to choose to work where they can most quickly reach that goal. Most have multiple job offers prior to graduation. Forcing a new graduate to conform to a rigid set of rules for where he or she must work is no longer in anyone's best interest. The same fundamental principles of holistic, family-centered care must be met whether the patient is on a medical-surgical unit or in an incubator in a neonatal intensive care unit (NICU). The profession and the public would be better served by exploring innovative ways to recruit, orient, and retain the best new professionals.


Regardless of the area in which they work, new graduates need a thorough orientation to their facility, including organizational philosophy, structure, documentation, and computer systems. New acute care nurses must be proficient in core areas that can be reviewed in a universal orientation, such as admissions, discharges, documentation, workplace safety, infection control, pain assessment and management, patient teaching, the use of devices (IV pumps, etc.), and the care of postoperative patients. Each specialty area requires additional orientation and periods of precepting. Given the costs of recruitment and orientation, the key element is not where the new graduate begins, but that there be a "good fit" between the workplace and the new hire. The new graduate who states a preference for a specialty and who is forced to forego that desire may quickly leave the institution, finding what they want elsewhere. Such turnover is costly; isn't it better that hiring be done for specific areas and overall turnover be minimized?


In today's world where we are encouraging nurses to adopt professional models of care, levels of autonomy, and professional career development, we should be helping new graduates to feel that they are a precious, valued resource. Healthcare facilities and new graduates each have a responsibility to determine the appropriateness of fit between employer and employee, and can determine this fit through joint discussions of position descriptions, career paths, and review of student clinical and work experiences.


Other healthcare professions have accepted this phenomenon; medicine no longer requires a rotating internship prior to beginning a specialty residency, and midwifery now offers a direct entry option. In my opinion, recruitment, orientation, career development, and retention are all linked. We need to offer new graduates positions in their area of choice, orient them to that specialty safely, help them become satisfied professional employees, and watch them become professional nurses who contribute to the safe care of patients.




American Associate of Critical Care Nurses. (2004). Nursing shortage fact sheet. Washington, DC: Author. [Context Link]


Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J. A., Busse, R., Clarke, H., et al. (2001). Nurse's reports on hospital care in five countries. Health Affairs, 20 (3), 43-53. [Context Link]


General Accounting Office. (2001). Nursing workforce: Shortages due to multiple factors. (GAO 01-944). Retrieved October 20, 2004, from [Context Link]