A colleague from a large school of nursing recently voiced concern about the career plan of many students she's encountered. Their plan, she said, is to gain experience in hospitals and then return to school to secure graduate degrees and practice as NPs. She thought that perhaps in emphasizing the need for nurses to provide community-based preventive care, we may have led many students to reject acute care bedside nursing as a desirable career.
I was curious to know if this trend was widespread, so I e-mailed colleagues across the country and asked. I received 32 responses.
Half of my colleagues agreed that most students were keen on pursuing an NP career after a few years in acute care:
- A Texas colleague cited a school survey showing that half of graduating students “wanted to get their DNP after one to two years’ experience as an RN.”
- A Michigan professor said virtually all students he meets talk about graduate school and NP practice within five years.
- From Nevada to Minnesota to New York to Florida, most respondents said that most new graduate nurses excitedly seek out and obtain acute care positions (preliminary results from the National Student Nurses’ Association's 2017 member survey indicated that 84% of new graduates are employed in acute care settings), but that many intend to leave them after two to three years to become NPs.
A few respondents felt that schools were pushing students toward advanced practice and DNP programs. A colleague from the South said, “There is a strong push from the university to encourage advanced degrees.” Another noted, “Being a frontline nurse is no longer a destination but rather a stepping-stone to something else. While it's true that we want to expand the number of advanced practice nurses, an unintended narrative has emerged. If you're a frontline nurse, you're in some way devalued.” Another said, “Nursing has not dealt with the long-term consequences of pulling nurses away from the hospital and traditional point-of-care roles to push the NP role.”
And while care is certainly (and necessarily) moving into community-based settings, it will require RNs as well as NPs. But where does that leave hospitals if most new nurses are setting their sights on a quick exit after a few years?
Undoubtedly some of the reasons behind nurses’ departure from hospitals is the hospital work environment itself. Few hospitals offer nurses autonomy or create environments that promote professional practice. Nurses may see advanced practice in community-based settings as more supportive of professional practice, offering more autonomy, less stress, and better scheduling. If hospitals are to retain nurses, workplaces must change.
Older, experienced staff are retiring just as the U.S. population will comprise a greater proportion of older adults with multiple comorbidities in need of care. (See AJN Reports in this issue.) Hospitals—and the nurses who work there—are already under enormous pressure as they deal with a rapid turnover of patients and staff. One respondent noted, “We commonly hear about the very disturbing ‘churn’ at the bedside as newer nurses come—particularly into critical care—to spend the minimum required time prior to heading to graduate school. This places a burden on tenured staff to continuously orient new nurses [who] then leave rather quickly.”
In this month's issue, two articles provide examples of why we need to ensure that new and well-educated RNs also see bedside nursing as a career. One article discusses a quality improvement initiative to reduce errors during patient handoffs, and the other focuses on early recognition of sepsis.
One of my colleagues sums up the issue well: “The narrative must be shifted to embrace the full range of roles and contributions of all nurses. Our health care system depends upon a well-trained, experienced workforce. The trend toward our hospitals being primarily populated with nurses with less than two years’ experience is worrisome.”