Year over year, we hear that new nursing graduates are not ready for practice. The numbers are clear; over the past 3 years the NCLEX pass rate for RNs has declined from 88.2% in 2019 to 79.9% in 2022 (NCSBN, 2022). In addition, only 23% of graduate nurses demonstrated entry level competence and readiness to practice (Kavanaugh & Szweda, 2017). The NCSBN has recognized that the current NCLEX exam did not adequately measure clinical judgement. Clinical judgement is defined as the process by which nurses make decisions based on nursing knowledge, evidence, theories, other disciplinary knowledge, critical thinking, and clinical reasoning (AACN, 2023). Starting in April 2023, the NCSBN will release the Next Generation NCLEX exam that improves testing of clinical judgement.
Clinical judgement: a necessary component of competency
Practicing nurses expect the nurse working beside them to be competent, confident and have their back if an emergency arises — essentially practice ready. The truth of the matter is that new graduate nurses are not practice ready because they are not fully competent; they are beginners. Being competent in nursing means being able to fully care for a patient in each situation by integrating knowledge, clinical judgement, skills, values, and attitudes to perform activities defined by their scope of practice (ANA, 2018). Clinical judgement is a component of competency; it does not mean one is competent. Based on Benner’s Novice to Expert Model, student nurses start at a novice level, meaning they have no professional experience and progress to a proficient level where they can recognize patient issues, are starting to utilize clinical judgement and learning to prioritize what has to be addressed first in patient care situations (Benner, 2020). It’s not until a nurse has 2 to 3 years of experience that they reach true competency. Today, healthcare organizations are facing an experience gap due to many of their most experienced nurses retiring or moving away from the bedside.
Healthcare organizations need to facilitate competency
Once a graduate nurse passes NCLEX and begins their transition to practice, that’s where the work begins to facilitate competency. Those in practice need to accept that graduate nurses will not be competent; it is the healthcare organizations responsibility to get them there through comprehensive orientation programs, nurse residency programs, mentorship, coaching, and monitor experiences. Healthcare organizations must provide a robust preceptor program and offer new graduates structure, resource support, and training as they progress through their orientation. While there is a push to get new graduate nurses independent and competent as quickly as possible, the results from pushing too quickly can be disastrous. The turn-over rate for graduate nurses at one year is 18% to 33% and increases by the second year (Blegan et al., 2017; Flinkman, Isopahkala-Bouret, & Salanterä, 2013). New graduate nurses leave when they do not feel they are being supported through their transition from beginner to competent nurse. Health care organizations that offer nurse residency programs have a much lower attrition rate than those who offer standard orientation programs (Knighten, 2022).
It's a partnership between academia and practice that ensures graduate nurse success
It’s obvious that academia or practice alone cannot insure nurse competency; it must be a partnership. Healthcare organizations that partner with academia through formal academic/practice partnerships where the students spend more clinical time within a healthcare organization and have oversight by preceptors and faculty with dual academic/practice appointments have demonstrated success in better preparing graduates and preventing attrition (Kennedy, 2020). Our healthcare organizations often struggle with the cost of longer, more comprehensive graduate nurse orientation programs or nurse residency programs. One needs to consider the return on investment on initiating and maintaining these programs. The average cost to fill a nurse vacancy is $46,100; if the organization can retain a new graduate and facilitate their professional growth from beginner to competent and finally expert clinician, the cost savings are substantial (NSI, 2022).
Investing in graduate nurses matters to our future
The Next Generation NCLEX examination is a first step to ensuring new graduate nurses are on their way to competency. However, experienced nurses and healthcare organizations need to change their perspective on how they think about nurse graduates. Recognize new nurse graduates are learning to use clinical judgement but it’s the organization’s and fellow nursing colleague’s role to facilitate their growth from beginner to competent nurse. We need to understand that the investment in new nurse graduates will build our ranks of competent nurses and the next time you’re faced with an emergency, you’ll know the nurse working beside you is competent, confident, and has your back.
American Association of Colleges of Nursing (AACN). (2023). The Essentials: Clinical judgement concepts. https://www.aacnnursing.org/Essentials/Concepts/Clinical-Judgement
American Nurses Association (ANA). (2018). ANA leadership: Competency Model. https://www.nursingworld.org/~4a0a2e/globalassets/docs/ce/177626-ana-leadership-booklet-new-final.pdf
Benner, P. (2020, August 1). From novice to expert. Nursology. https://nursology.net/nurse-theories/from-novice-to-expert/
Blegen, M. A., Spector, N., Lynn, M. R., Barnsteiner, J., & Ulrich, B. T. (2017). Newly Licensed RN Retention: Hospital and Nurse Characteristics. The Journal of nursing administration, 47(10), 508–514. https://doi.org/10.1097/NNA.0000000000000523
Flinkman, M., Isopahkala-Bouret, U., & Salanterä, S. (2013). Young registered nurses' intention to leave the profession and professional turnover in early career: a qualitative case study. ISRN nursing, 2013, 916061. https://doi.org/10.1155/2013/916061
Kavanagh, J. M., & Szweda, C. (2017). A Crisis in Competency: The Strategic and Ethical Imperative to Assessing New Graduate Nurses' Clinical Reasoning. Nursing education perspectives, 38(2), 57–62. https://doi.org/10.1097/01.NEP.0000000000000112
Kennedy, S. (Facilitator). (2020, November 5). Practice/Academic Partnerships in the Age of COVID: You Can Do This! (in partnership with the National Council of State Boards of Nursing) [Webinar]. American Journal of Nursing. https://journals.lww.com/ajnonline/Pages/video.aspx?autoPlay=false&v=156
Knighten M. L. (2022). New Nurse Residency Programs: Benefits and Return on Investment. Nursing administration quarterly, 46(2), 185–190. https://doi.org/10.1097/NAQ.0000000000000522
Nursing Solutions, Inc. (NSI). (2022). 2022 National healthcare retention and RN staffing report. https://www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_Care_Retention_Report.pdf