Casey, Kathy MS; Fink, RN Regina PhD, RN, FAAN; Krugman, AOCN Mary PhD, RN; Propst, FAAN Jennifer BSN, RN
Graduate nurse transition from an educational program into the practice setting has been widely recognized as a period of stress, role adjustment, and reality shock. 1–4 Whereas these challenges have been documented since the early 1970s, there is renewed urgency to examine graduate nurse perceptions of the initial practice experience because of concerns about retention. Graduate nurses are becoming a significant part of hospital recruitment and staffing strategies 5 as nursing workforce shortages become a reality, yet graduate nurse turnover is estimated to range from 55% to 61%. 6 Recently, the Nursing Executive Center of the Advisory Board 5 surveyed 121 graduate nurses at both teaching and nonteaching hospitals, reporting that although 77% of graduate nurses are committed to developing a professional career in nursing, 31% of those younger than 24 years expect to change their position within the next 2 years. These data have significant implications for acute care hospitals because the 2-year point after new graduate nurse hire is often when the clinical nurse starts to assume a leadership role on a service as a fully functional team member. Graduate nurse turnover is costly for acute care hospitals because it includes not only the cost of orientation, estimated most recently at $33,841, 7 but also replacement costs, which increasingly translate to spending premium labor dollars associated with registry or traveler nurses because of the nursing shortage. 4
Although there are many published reports of graduate nurse experiences, the data are widely variable, ranging from anecdotal narratives to surveys done on a one-time basis, often with a limited sample size. Persistent themes reported to influence the graduate nurse experience are the consistency of role socialization support, 8,9 the quality of the clinical orientation, 10–12 and the level of nursing leadership support, including knowledge and sensitivity to the phases and stages of professional nurse transition and development. 13–16 Based on informal feedback from graduate nurses in the Denver metropolitan area, the authors initiated a study to investigate how graduate nurses’ experiences change with time as they transition into the professional nurse role.
Purpose of the Study
The intent of the study was to identify the stresses and challenges experienced by cohorts of graduate nurses working in 6 Denver acute care hospitals during specific timed data periods: at baseline, 3 months, 6 months, 12 months, and an additional continued follow-up of specific groups for a longer employment period. Graduate nurses were surveyed to determine if there were similarities or differences in demographic profiles, skills, or procedures they found difficult to perform, level of comfort and confidence in their new role, organizational support, and differences in self-reported job satisfaction. Qualitative themes of their perceived challenges experienced during the first year of employment are also reported.
The investigators selected a descriptive, comparative design using survey questionnaire methods to study graduate nurse experiences in 6 institutions during timed data periods in the first year of transition into practice. The research was approved by the appropriate institutional review boards as an expedited study. There were 2 phases of data collection. The instrument used to survey the new graduates was developed by the investigators and pilot tested during phase 1 of the study. The instrument was further revised over time to better measure work environment issues not included in the original pilot instrument. During phase 2 of the study, the revised surveys were distributed only to new graduates at the academic teaching hospital.
Sample and Setting
The study consisted of a convenience sample of 270 new graduate nurses from 6 acute care facilities in the Denver metropolitan area. The study sites encompassed 1 academic teaching hospital, 3 private for-profit facilities, and 2 private not-for-profit hospitals. Participants were recruited by asking all new graduate nurses at each facility to voluntarily complete a survey. A total of 784 surveys were distributed; 270 respondents agreed to participate (34% response rate).
Data Collection Procedures
A site coordinator was identified from the staff development office at each facility to manage study procedures. The new graduates were asked to voluntarily participate, study procedures were outlined, and data collection was initiated. In phase 1 data collection, surveys were distributed to various cohorts of new graduate nurses at all 6 facilities from June 1999 to July 2001. In phase 2 data collection, a revised survey was distributed to graduate nurses at the academic teaching hospital who were entering an expanded graduate nurse residency program. Data were collected using confidential procedures to assure anonymity of participants.
The Casey-Fink Graduate Nurse Experience Survey© was developed, piloted, and revised to measure the new graduate nurse’s experience on entry into the workplace, then through the transition into the role of professional nurse. The content of the tool was derived from a comprehensive literature review. The tool was piloted on 12 graduate nurses and tested for content validity using an expert panel of nurse directors and educators in both academic and private hospital settings. More than 250 nurses in hospital settings in the Denver metropolitan area were surveyed during a 3-year period. Each data collection period afforded an opportunity to conduct psychometric analysis of the instrument, with revisions made to clarify potentially ambiguous items. These revisions were not substantive and consisted of subtle wording changes in less than 3 questions and the addition of 5 statements related to comfort and confidence. The instrument was determined to discriminate between nurses with varied amounts of experience during the first year of practice. Internal consistency reliability was established on the original instrument, with a Cronbach’s alpha of .78 on items reflecting levels of comfort and confidence with various practice skills. Additional reliability testing on the revised instrument indicated little change in internal consistency.
The revised Casey-Fink Graduate Nurse Experience Survey© consists of 5 sections: demographic information; skills/procedure performance (3 open-ended questions); comfort/confidence (25-items with Likert scale response with 1 = strongly disagree and 4 = strongly agree); 9 items on job satisfaction dimensions; and 4 open-ended questions about work environment and difficulties in role transition. Demographic data questions include age, gender, ethnicity, specialty area, date of graduation, degree received, previous healthcare work experience, date of hire, length of time at the current hospital, number of preceptors during orientation, and length of unit orientation. The instrument takes approximately 15 to 20 minutes to complete.
Data were entered into the Statistical Package for the Social Sciences program (SPSS, Chicago, IL) by a research assistant and analyzed by site, items, demographics, and aggregate groups over time. Data are presented by demographics and by categories of the survey instrument. Alpha was set at 0.05.
Demographic profiles were analyzed for phase 1 and phase 2 respondents. The average respondent was a white woman 35 years of age or younger, with previous healthcare experience as a volunteer, nursing assistant, unit secretary, or licensed practical nurse. More respondents (95%) at the academic teaching hospital had a bachelor of science in nursing (BSN) as entry into practice than did other site respondents (71%), because this is the only type of graduate nurse hired. In addition, the number of preceptors assigned to the new graduate varied widely between phases 1 and 2. More than 59% of respondents at the academic teaching hospital had more than 3 preceptors during their orientation period, potentially because of the extended orientation (as long as 6 months in many specialties), as compared with 39% of respondents at other sites. The distribution of the total sample (N = 270) included 47% at the academic hospital, with the remaining 53% distributed among the 5 community hospital sites.
The graduate nurses practiced in a wide variety of clinical areas, including critical care, medical/surgical, and specialty services, such as psychiatry, rehabilitation, and women’s services. The length of medical/surgical new graduate orientation programs varied by hospital and ranged from 6 to 10 weeks at the for-profit and not-for-profit facilities to 12 to 24 weeks at the academic teaching hospital. New graduates were surveyed at various times during their first year of practice. The data were divided into 4 time periods based on length of time in the registered nurse (RN) role (0–3 months, >3 and ≤6 months, >6 and ≤12 months, >1 year). Because of the timing of the data collection period, there were no respondents in phase 2 of data collection who were in the >1 year of practice category.
Skills and Procedure Performance
New graduates (n = 209) who were surveyed using the first edition of the survey during the data collection periods from June 1999 through July 2001 were asked to choose the top 3 skills and procedures they were uncomfortable performing from an investigator-generated list of 18 commonly performed nursing activities and interventions. Because many additional skills and procedures were added to the list by respondents, a revision was made to the survey so that respondents from subsequent data collection time periods (n = 61) self-entered their own top 3 skills and procedures they were uncomfortable performing. All skills from both survey versions were combined and analyzed over time.
Only 4% of graduate nurse respondents were comfortable performing all skills and procedures. Most respondents identified 54 different procedures and skills that proved uncomfortable on hire; of these skills, greater than 15% of respondents identified 7 as the most challenging over time (Figure 1). It is important to note that even after 1 year of practice, 41% of new graduates in this sample were still uncomfortable caring for patients with epidural catheters.
Comfort and Confidence
There were 20 statements on the original instrument related to graduate nurse perceptions of their levels of comfort and confidence while functioning as a professional nurse. Five additional questions were added to the revised version of the survey in phase 2 in an effort to understand the support provided to new graduates by their preceptors, manager, and peer nursing staff. When all phase 1 and 2 subjects’ results were combined, of the total 25 statements related to comfort/confidence, 5 were statistically significant using chi-square analysis.
Initially, graduate nurse respondents felt less confident communicating with interns and residents but gained confidence between 6 months and 1 year (χ2 = 28.15; P = .001). Similar findings were reported related to communicating with attending physicians (χ2 = 25.02; P = .003). The graduate nurse comfort and confidence significantly improved between 6 months and 1 year of practice in the areas of delegating to ancillary personnel (χ2 = 32.78; P = .005), setting priorities for and organizing patient care needs (χ2 = 25.86; P = .002), and making suggestions for changes to the nursing plan of care (χ2 = 40.30; P < .001)
One hundred (37%) respondents were uncomfortable caring for dying patients, and there was no improvement with time. Almost all (99%) respondents were comfortable communicating with patients and their family members and felt supported by their own family and friends in their work. However, 126 (47%) new graduate nurse respondents stated they were experiencing stressors in their personal life; 25% stated their stress was caused by finances and student loans.
A comfort/confidence score was established based on 18 items that were the same on all versions of the survey. When the results of all respondents (n = 270) were combined (phases 1 + 2), there was a statistically significant difference in comfort/confidence score by level of experience using analysis of variance (ANOVA) testing procedures (Table 1). Graduate nurses initially starting practice rated themselves as being comfortable and confident in their role (χ̄ = 55.03). However, between 3 and 12 months this confidence level declined from χ̄ = 54.28 (3 months) to a low of χ̄ = 53.68 at 6 to 12 months. After 1 year of practice, comfort and confidence in the RN role increased to a high χ̄ = 57.92.
All respondents (N = 270) were queried about job satisfaction, which included 9 items related to salary, benefits, and work schedule. Although results reported only 39% were satisfied with their salary, 70% were satisfied with their benefits package, and 65% were satisfied with vacation time. Eighty-four percent of graduate nurses reported satisfaction with their overall hours worked, but only 41% were satisfied with the opportunity to work straight days. Weekend schedules were rated at 65% satisfaction. The level of satisfaction with positive feedback from preceptors, managers, and co-workers was moderately high, at 73%. Finally, 40% of new graduates perceived they lacked opportunities for future career development in their employment setting.
The total job satisfaction mean score was calculated for phase 1 (n = 167) (χ̄ = 31.35 ± SD 5.403) and phase 2 respondents (n = 61) (χ̄ = 33.18 ± 4.249), excluding nurses with greater than 1 year experience because of lack of respondents in that phase 2 category. Phase 1 respondents became less satisfied with their jobs as they gained experience in the RN role (P = .02). However, phase 2 graduate nurse respondents at the academic teaching hospital reported significantly higher job satisfaction than did phase 1 respondents from all other sites (P = .008).
Difficulty With Role Transition
The last part of the survey included a series of open-ended questions that permitted the graduate nurses to give voice to their personal experiences. In response to the question, “What difficulties, if any, are you experiencing with the transition from ‘student role’ to the ‘RN role’,” 6 overall themes were identified. Key words from respondent narratives were independently identified for each timed data collection period by the 4 investigators. The investigators then compared their findings to obtain inter-rater reliability across the sample. Six themes were consistently identified across all institutions and all time periods. The following summary lists the themes in order of how frequently and intensely the graduate nurse respondents reported them to be most difficult to their transition:
1. lack of confidence in skill performance, deficits in critical thinking and clinical knowledge;
2. relationships with peers and preceptors;
3. struggles with dependence on others yet wanting to be independent practitioners;
4. frustrations with the work environment;
5. organization and priority-setting skills; and
6. communication with physicians.
Throughout the first year of practice, graduates expressed feelings of inadequacy with their clinical knowledge, deeming themselves incompetent to care for their patient assignment. They were unsure of their ability to learn new skills and were anxious and “scared about making patient care decisions.” Many wrote, “I was expected to have all the answers for my patient’s questions” and described difficulties with implementing “textbook standards of care versus the real world of care.” Toward the end of the first year of practice, graduates reported that they were starting to gain confidence in their ability to think critically and reported starting to “get comfortable in their role.” These graduate experiences mirrored the descriptions by Benner et al, 15 who noted the advanced beginner moves from acting like a nurse, to coming into her own and being a nurse.
Peer and Preceptor Relationships
Graduates voiced concerns about peer and preceptor relationships. Many graduates stated they felt a lack of acceptance and respect from the experienced nurses and disliked being called “the new grad.” They verbalized frustration, perceiving preceptors were not “in tune with” what it was like to be a new graduate and therefore were not sensitive to their needs for continued development in time management skills. Many stated a lack of “consistent preceptors during orientation” contributed to their lack of proficiency. Some graduates voiced a lack of positive support and verbal feedback from preceptors and peers. They were fearful about “speaking out” and verbalized a need “to earn the trust of coworkers,” findings similar to those of Thomka, 8 who reported graduates feared retribution or were reluctant to report poor preceptor treatment.
Other new graduates described positive experiences with their preceptors, verbalizing they felt comfortable asking for help. For many graduates, having other new graduate peers available to talk to and share clinical experiences was identified as a “relief” and a support.
Dependence and Independence
This theme refers to the graduates’ abilities to handle their new level of responsibility. They struggled with the dichotomy of needing to be independent yet continuing to rely on the expertise of others, findings similar to those of Duchscher, 17 who interviewed graduates experiencing enormous frustration with this issue. Across all time frames, the struggle between dependence and independence was evident. Comments included “feeling alone,” “on my own with a tremendous amount of responsibility,” and “feeling overwhelmed.” Some felt “babied” during orientation, not able to develop the necessary skills to acquire RN role responsibilities. In contrast, another graduate stated, “there is no one telling me what to do!”
Others struggled with their delegation skills, verbalizing feelings of “guilt” and “frustration” when not comfortable asking ancillary personnel for help, yet adding to their own workload. By the close of the first year of practice they described being able to “let go of the dependence on others.”
Many graduate nurses described their work environments as being “understaffed,” expressed being overwhelmed with the “nurse-to-patient ratio,” and voiced concerns with the “nursing shortage and retention of unit staff.” During their first 6 months of practice, the nurses’ comments often related to the difficulty in adjusting to shift work (rotating from day to night shift), a perceived lack of time off with “no school vacations,” and frustrations with pay. At 9 months of practice, a few graduates described being placed in the charge nurse and preceptor roles, expressing concern about assuming this level of role expectation.
Organization and Priority Setting
Graduates with fewer than 6 months of experience most often indicated that lack of organization skills seemed to be a key barrier to optimal performance in their new role. They described having a hard time determining a “routine of their own” to make things run smoothly, “being disorganized,” “not efficient,” “task-focused,” “not being able to find time to chart,” and “not having enough time to think and organize in order to provide safe care.” “Difficulty prioritizing tasks” and “I’m slower” were common statements. They were concerned with the amount of new information and skills they needed to integrate while trying to be timely in their care delivery. Having to use multiple references and resources made tasks and care delivery “take 3 times as long as it should.”
The graduates had high expectations for themselves of what could be accomplished in an 8- to 12-hour shift. They described having difficulty leaving work “on time.” Again, as time progressed, their skills in time management and setting priorities regarding patient needs became more proficient. Ellerton and Gregor 18 identify this issue as a challenge to competent practice, describing how graduate nurses were handicapped before even leaving the nurses’ station by the time taken for such activities as reviewing a record for 40, rather than 10, minutes; looking up medications with which they were unfamiliar; and consulting on unfamiliar diagnoses.
Effective communication is integral to the success of any work environment. New graduates identified a lack of experience communicating with physicians on their units. While the nurses were students, most of their physician contact was with the support of a preceptor or instructor. Throughout the first 6 months as professional nurses, they felt insecure and lacked confidence knowing which physician to call and when to call, and had difficulty “deciphering orders and signatures” and then interpreting their orders. They verbalized a lack of respect from their physician counterparts and were hampered by their difficulties communicating patient problems. These difficulties were not expressed during the last 6 months of their first year.
Many of the above-mentioned insecurities lessened with time. At 1 year, new graduate nurses still verbalized problems with organization and delegation, but their primary frustrations focused on peer relations and work environment issues, which included lack of feeling valued and lack of financial rewards. They began to doubt their choice of profession and in some cases were already talking about being “burned out.”
In phase 2 of the study, 4 additional qualitative questions were asked of the academic teaching hospital graduate nurses. These graduates were participating in a hospital-wide graduate nurse residency program that was initiated in June 2001, an expansion of a smaller specialty program previously in place. The survey tool was revised to provide an assessment of job satisfaction with the current work environment, level of unit support for graduate nurses, and an opportunity for the graduates to share any concerns about the new graduate nurse residency program.
Most of the respondents from the phase 2 survey questions were in the group that was in the time period 6 to 12 months after hire. When asked, “What could be done to help you feel more supported or integrated into the unit,” many stated: “the staff is great, very inclusive and welcoming.” Others identified that a consistent preceptor would have been helpful. Some graduates expressed a desire to have a mentor available to answer their ongoing questions, whereas others asked for more feedback and encouragement, especially surrounding issues of time management and mastering new procedures.
When asked about their perceptions of the graduate nurse residency program, most respondents appreciated the longer orientation period. They described the interactions with other new graduates offered “moral support.” However, many reported that having too many didactic classes at the beginning of the program was overwhelming. In response to satisfaction with the work environment, most graduates described satisfaction with their patient/family interactions, enjoying “listening to their patient stories.” Staff support, teamwork, and “learning new things every day” were also cited. The least satisfying aspects included frustrations with a perceived increased workload, generational differences in the RN team, difficulty with working rotating shifts, and “poor pay.” This feedback was used to redesign the residency program, in collaboration with the development of the American Association of Colleges of Nursing (AACN) and University HealthSystem Consortium (UHC) National BSN Residency Demonstration Project, 19 which was implemented in June 2002. The academic teaching hospital in this study became one of the original 6 participating sites.
Tracking graduate nurses for repeat measures in 6 hospital sites proved complex. A study limitation was a decreased response rate and attrition with time, resulting in fewer subjects at some sites by the close of the 1-year time period. This could have potentially affected the validity of the results. The lack of consistency of the cohort group of respondents changed somewhat with time (eg, the percent of hospital new graduates who completed survey), which also could have potentially affected the study results.
Because the instrument used in this study was under development with multiple revisions, its structure/format did not facilitate ease of administration and analysis. Quantitative and qualitative sections were intermixed; making the tool difficult to score. The final revised instrument is being used in a multisite study of graduate nurses participating in the National Residency Demonstration Project 19 and this larger number of subjects will permit additional insights into the tool’s validity and reliability.
Graduate nurses participating in the current study reported many transitions into practice experiences previously documented in the literature: stress, feelings of inadequacy, and deficits in both skill and knowledge domains. 1–3 A key finding, that graduate nurses perceived it took at least 12 months to feel comfortable and confident practicing in the acute care setting, is a time frame that extends far beyond the standard orientation and support provided by most hospitals. The data clearly demonstrate the most difficult role adjustment time period for graduate nurses is between 6 and 12 months after hire. These findings were consistent across the 6 acute care settings, indicating the process of moving from graduate to competent nurse takes time, supervision, and support in both community and academic hospital settings.
Although it is not uncommon for any new graduate to experience some feelings of inadequacy when entering the job market, most do not have the confidence and competence to assume the level of responsibility for patient safety that is characteristic of the nursing profession. Many hospitals view graduate nurses as an immediate solution to staffing shortages, rather than a long-term strategy for professional development and retention. It is not uncommon for hospitals to curtail the length of new graduate orientation to meet the demands of unit schedules. Data from this study, such as 41% of graduate nurses still feeling uncomfortable caring for patients who have epidural catheters 1 year after hire, indicate the potential risks to patient safety without well-managed training and incrementally staged patients responsibilities.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) published a major white paper on the nursing shortage and its underlying causes, setting forth recommendations that included funding of nursing internships of at least 1 year after graduation. 20 Results of the current study reinforce this JCAHO recommendation, showing that graduate nurse respondents in the academic teaching hospital who were in the second 6 months of their residency program, having experienced an extended orientation and a year-long support program, held higher job satisfaction ratings. These findings provide a strong rationale for graduate nurse residency programs that extend beyond orientation and provide support through the first year of practice, such as the AACN/UHC National BSN Residency Program 19 and the Los Angeles Children’s Hospital Pediatric Residency Program. 21
A second key finding is how significant the preceptor role is to graduate nurses’ job satisfaction and their developing competency in the professional role. Preceptors may not realize how critical is their support as graduate nurses balance the tension between independence and dependence during the initial socialization period. Preceptors need formal education regarding the value and impact of their role, and to better understand reality shock, 1 Benner’s 13 descriptions of the advanced beginner, clinical teaching strategies, learning style differences, generational differences, and communication strategies.
Preceptors are key to facilitating the graduate nurse’s personal adjustments to the practice role and strongly influence how professional behaviors are role modeled. Although the current study cannot make definitive recommendations on the ideal number of preceptors during orientation, it is clear many graduates do not feel their orientation progressed smoothly when the numbers of preceptors exceeded more than 3 during the orientation period. The effect of multiple preceptors can be mediated by a consistent and involved senior member of the staff, such as a residency coordinator, educator, or manager, who oversees the process and ensures there is continuity of graduate nurse learning across the shifts and different preceptors.
Santos et al 22 studied stress, strain, and coping of inpatient Baby Boomer nurses born between 1946 and 1964, and found the greatest degree of stress related to the physical environment and responsibility, with these nurses reporting role overload and interpersonal strain. These Baby Boomer nurses are often the primary preceptors for graduate nurses, potentially influencing how graduate nurses perceive their own professional future. Continued evaluation and research on preceptors and their ability to mentor new graduates while experiencing work strain should be undertaken.
There are many institutional strategies that may be implemented to ensure that the environment of continued support and learning for graduate nurses continues beyond orientation, including adding off-shift educators, a special mentor program, or residency facilitators. The key element is to structure some type of formal support mechanism so that both graduate nurses and the institution can ensure continued instruction and patient safety. The Advisory Board Nurse Executive Center 5 notes that 22% of the 121 graduate nurses surveyed felt they were not supported by staff, and 31% felt they were unsupported by their managers. Establishing a climate of support with management actively involved in graduate nurse development can improve ongoing socialization and mentoring and plays a vital role in their overall job satisfaction, feelings of belonging, and success with role transformation.
Although a well-managed residency program that includes trained preceptors, support sessions focusing on critical thinking development, and patient safety can promote best practices for graduate nurse transition, it is of concern that so many graduate nurses in this study voiced dissatisfaction with the work environment and frustration with their perceived lack of power to make effective changes. These feelings of frustration, coupled with a 40% perceived lack of opportunities for career development, 39% dissatisfaction with salary, and 41% dissatisfaction with their schedules, sound the warning for the need to address workforce issues beyond the scope of graduate nurse training and education. Workforce issues have been under examination by numerous organizations, including the American Organization of Nurse Executives. These efforts are essential to the retention of graduate nurses.
New graduate transition from student to professional nurse requires consistent support and professional development during the first year of practice. Closer partnerships between the academic and practice institutions could facilitate an improved integration in this transition process. Additional research is indicated regarding the effect of graduate nurses’ personal and financial stressors because preliminary evidence in this study highlighted issues related to finances, which may include debts associated with education to become a nurse and the costs associated with starting an independent career after graduation. Finally, research tracking graduate nurse care outcomes compared with outcomes of experienced nurses would be beneficial to contribute insights into potential gaps in the preparation of students for transition into practice, as well as how to create improved systems of support for the graduate nurse during the first year of practice. Initiatives such as formal 1-year graduate nurse residency programs provide a way to close the gap between the new graduate nurse lacking comfort, confidence, and skill proficiency and the professional nurse who has developed into a safe and competent clinical nurse.
The authors acknowledge the work and dedication of the following nurses who assisted in data collection and management: Michelle Hobbs, MS, RN, University of Colorado Hospital; Kathy Bader, MS, RN, Exempla/Lutheran Medical Center; Sandie Kerlagon, MS, RN, and Sheila Morgan, MS, RN, Health One/Swedish Medical Center; Judy Hiester, MS, RN, and Carol Herring, MS, RN, Health One/ Presbyterian/St. Luke’s Medical Center; Sylvia Kitzman, BSN, RN, St. Anthony’s/Centura Medical Center; Joyce Thomson, MS, RN, Health One/Rose Medical Center; Laura Sasse, ND Nursing Student/ Research Assistant, University of Colorado Hospital/ Health Sciences Center; and Lisa Jones, BA, University of Colorado Hospital.
© 2004 Lippincott Williams & Wilkins, Inc.