Essential nursing competencies such as confidence, effective and efficient communication, problem-solving, clinical reasoning and judgment required for clinical decision-making, working independently, and effectively collaborating within multidisciplinary healthcare teams have been cited as lacking in many of today’s new graduate nurses (NGNs; Brown & Crookes, 2016; Kavanagh & Szweda, 2017; Murray, Sundin, & Cope, 2018; Spector et al., 2015; Theisen & Sandau, 2013). Over a decade ago, the Institute of Medicine’s (IOM, 2010) landmark report, The Future of Nursing: Leading Changes, Advancing Health 2010 Focus on Education, identified that most of the NGNs were not adequately prepared to assume the challenging and complex role of today’s professional nurse. That same year, the Carnegie Foundation for the Advancement of Teaching called for a “radical transformation” in nursing education (Benner, 2010, p. 3). Both the IOM (2010) and the Carnegie Study urged academic and practice organizations to collaborate to address the difficulties NGNs experience in transitioning from student to practicing professional (Benner, 2010). Despite these recommendations, current research suggests that many NGNs continue to be unprepared for practice. Faculty and students participating in traditional clinical (TC) teaching models, where one faculty is responsible for teaching and supervising 8–10 students in the clinical setting, often report having insufficient time for individual student teaching and supervision, being viewed by clinical staff as visitors, and lacking opportunities for student professional role development (Luhanga, 2018).
Unprepared NGNs are at great risk of experiencing stress and difficulty transitioning into their new roles (Benner, 2010; Frögéli, Rudman, Ljótsson, & Gustavsson, 2018; Hickerson, Taylor, & Terhaar, 2016; Ortiz, 2016; Tong & Epeneter, 2018; Van Rooyen, Portia, Ham-Baloy, & Caka, 2018). Kramer (1974) termed this experience “reality shock.” Reality shock hinders NGNs’ performance and socialization into the profession, negatively affecting retention rates while also increasing attrition and healthcare costs and compromising patient safety (Ebrahimi, Hassankhani, Negarandeh, Gillespie, & Azizi, 2016; Hickerson et al., 2016; Hofler & Thomas, 2016; Hussein, Brownwyn, Ramjan, Hu, & Salamonson, 2017; Spector et al., 2015; Van Rooyen et al., 2018). An estimated 17.5% of NGNs leave their first job within the first year, and one in three (33.5%) leave within 2 years, costing the U.S. healthcare system $1.4 billion to $2.9 billion per year (Kovner, Brewer, Fatehi, & Jun, 2014; Meyer, Shatto, Delicath, & Von der Lancken, 2016). Among the reasons cited for NGNs’ leaving the profession include lack of support, unwelcoming clinical environments, low confidence and sense of competence, and overall feelings of stress and unpreparedness for their new roles (Hickerson et al., 2016; Hussein et al., 2017; Kovner et al., 2014; Murray et al., 2018; Shatto & Lutz, 2017).
Preparing NGNs to practice in today’s complex and dynamic healthcare environment requires dedicated and coordinated responses from both academic and practice organizations (Arkan, Ordin, & Yılmaz, 2018; Huston et al., 2018; IOM, 2010; Shepard Battle, 2018; Spector et al., 2015; Van Rooyen et al., 2018). Although responsibilities of NGNs have changed dramatically over the past 30 years, clinical teaching models have not kept pace with these changes. Traditional models of clinical education continue to be considered the gold standard of clinical nursing education (Luhanga, 2018). To date, there is a lack of evidence identifying the effectiveness of this model as “best practice” with respect to student learning and patient safety (Jayasekara et al., 2018). Among reported challenges of the traditional model, the most concerning is the inability of a single faculty member to effectively balance students’ learning with patient safety (Luhanga, 2018).
Recent research has, however, pointed to a promising model for transitioning new nurses from student to professional: dedicated education units (DEUs). DEUs are clinical units within hospitals where baccalaureate-prepared registered staff nurses, recognized by their nurse managers as clinical experts, are trained and coached by academic faculty to serve as clinical instructors (CIs) for undergraduate nursing students (Edgecombe, Wotton, Gonda, & Mason, 1999; Moscato, Miller, Logsdon, Weinberg, & Chorpenning, 2007). This model pairs two students with one CI for a designated number of hours per week during a clinical rotation to optimize the clinical teaching/learning environment. The CI supports students with applying learned classroom theory and clinical skills to real-world practice (Edgecombe et al., 1999; Moscato et al., 2007). In this innovative model, academic faculty provide ongoing coaching and mentoring to staff nurses in their roles as CIs and support students with meeting course objectives by challenging them to apply critical thinking and clinical reasoning skills to solve real-world problems (Edgecombe et al., 1999; Moscato et al., 2007; Rhodes, Meyer, & Underhill, 2012). The DEU academic–practice partnership requires collaboration, commitment, and careful planning (Dimino, 2018). DEUs have been identified as being superior to traditional models in engaging nursing students in the clinical learning environment, promoting clinical self-efficacy and positive attitudes toward team processes, and enhancing student learning (George, Locasto, Pyo, & Cline, 2017; Jayasekara et al., 2018; Plemmons, Clark, & Feng, 2018; Schecter, Gallagher, & Ryan, 2017). In addition, Masters (2016) identified that students who participated in a DEU had higher Quality and Safety Education for Nurses knowledge scores compared to those with TC experiences.
The original DEU model was introduced in the 1990s by nursing faculty from Flinders University in Australia and adapted by the University of Portland in 2003. The impetus for implementing DEUs in the United States was a need to address the limitations of TC teaching models, the identified need to better prepare students for real-world practice while decreasing the number of clinical faculty required to teach, and improving and enhancing academic–practice relationships (Dapremont & Lee, 2013; Edgecombe et al., 1999; IOM, 2010; Moscato et al., 2007).
Several recent studies have suggested the efficacy of DEUs as a strategy for transitioning nursing students into professional practice. Saxton, Warmbrodt, Mahley, Reberry, and McNeece (2015), for example, conducted a qualitative study involving two focus groups to explore the experiences of students and staff nurses participating in DEUs. The first group consisted of 15 (N = 15) second-semester juniors. Themes from the student group were identified as consistency, whole picture thinking, professional role development, and sense of investment in student learning. Researchers reported students expressed appreciation that working side by side with DEU nurses enabled them to participate in the entire care of their patient. Student participants also identified DEU nurses as role models who provided opportunities for learning clinical skills and professional behaviors, including communication and collaboration. Students expressed feeling welcomed on the unit and that the entire unit was invested in their learning. The second focus group consisted of six (N = 6) DEU nurses. Themes identified included “real-world” nursing, learning to teach, and collegiality. The DEU nurses commented that the 12-hour DEU shifts allowed students to experience the “real world of nursing.” The DEU nurses expressed appreciation for CI training and shared that they felt prepared and comfortable in their new roles. Professional collegiality in the DEU was recognized as a benefit in this study, as nurses shared teaching experiences and supported each other with identifying various strategies to teach and interact with their students.
In another study of DEUs’ effectiveness, Heidelburg (2017) conducted a quantitative pilot study using a descriptive design to explore registered nurses’ (RNs) beliefs regarding preparedness of nursing students who had completed a DEU program (N = 33). Data revealed that 100% of participants believed that the DEU program increased competency and prepared students for professional practice. Moreover, 90% of the RNs reported increased student confidence to practice upon completion of the DEU program. Heidelburg (2017) identified that RNs believed the DEU was a worthwhile clinical approach in preparing NGNs for practice. Heidelburg (2017) concluded that the DEU provided nursing students with a unique opportunity to acclimate themselves to the culture of the real world of nursing while experiencing “improved confidence and knowledge of patient care” (p. 83).
A plethora of literature reports high satisfaction rates for DEUs among administrators, faculty, students, and frontline staff (George et al., 2017; Moscato et al., 2007; Mulready-Shick, Flanagan, Banister, Mylott, & Curtin, 2013; Rhodes et al., 2012; Schecter et al., 2017). Most studies, however, are limited to reporting qualitative outcomes; few discuss quantitative outcomes, especially as they relate to NGNs’ transition to practice (George et al., 2017). In fact, there has been no measurement to date of transition to practice. This literature provides context for the present research’s exploration of the impact of the DEU on NGNs’ role transition.
The purpose of this mixed-method study was to explore the impact of a DEU on role transition of NGNs. The DEU for this study was established in 2012 between a large public university in New Jersey and one of the largest academic medical centers and providers of charity care in the state.
An electronic Revised Casey–Fink Graduate Nurse Experience Survey (Casey & Fink, 2006) was used to compare transition experiences of NGNs from the same BSN program who completed 120 clinical hours over a 16-week rotation during their senior year of nursing school in either a DEU clinical experience or a TC experience. Semistructured interviews were used to explore acute care nurse managers’ expected competencies of NGNs and compare their experiences hiring and working with NGNs from their academic partners’ DEU program to NGNs without DEU experience.
After receiving institutional review board approval from the university, a convenience sample was obtained from the alumni association, and potential participants were invited to participate in the survey via e-mail. Inclusion criteria included being a university BSN graduate between January 2012 and May 2018 and working as a new graduate in an RN position within 1 year of graduation. Voluntary completion of the survey provided passive consent. Participants were informed that agreeing to participate in the study would ensure their names and identification would not be reported. Completion of the survey took approximately 10–15 minutes. The Revised Casey–Fink Graduate Nurse Experience Survey (Casey & Fink, 2006) consists of five sections: demographic information, self-reported skills/procedure performance, comfort/confidence (25 items with Likert scale response, from 1 = strongly disagree to 4 = strongly agree), and nine items on job satisfaction dimensions. An index was computed by combining responses to comfort/confidence items. Additional survey items examined life stressors and transition difficulties as well as demographic data. Demographic data questions included age, gender, ethnicity, and year of graduation. 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. For this study, an additional demographic question asked respondents whether they completed their senior clinical hours (120 hours over a 16-week period) in a DEU or a TC environment. Differences in performance were measured on the Revised Casey–Fink New Graduate Experience Survey (Casey & Fink, 2006) between alumni who experienced a DEU clinical teaching model in their senior year of nursing school and those who experienced a TC teaching model using independent-samples t tests and one-way analyses of variance as appropriate based on number of response categories in the independent/grouping variables. The final question of the electronic survey asked NGNs to share comments or concerns they experienced or were experiencing in their first position as an NGN. The responses were compared by clinical program, and similarities and differences in the two groups were noted. The survey was anonymous.
After receiving institutional review board approval from the medical center, nurse managers were invited via e-mail to participate in the interviews. The investigator then sent each participant a follow-up e-mail to schedule a mutually convenient time. The purpose of the study was reviewed. Active consent was obtained from interview participants prior to beginning the interview. The interview took about 15 minutes. The following questions were used to elicit NGNs’ competency expectations and their experiences working with DEU-trained versus non-DEU-trained NGNs:
(1) How do you define competency? (2) What qualities do you think contribute to a successful transition for a new nurse beginning practice? (3) Do you see any differences between NGNs you have hired who have had DEU experience as an undergraduate nursing student from those who have not? If so, please explain.
Interviews were recorded and transcribed line by line by the primary investigator. Transcribed documents were de-identified. Concepts and themes were extracted and analyzed to describe data according to Graneheim and Lundman (2004).
This mixed-methods retrospective study compared NGNs who had graduated with their BSN from the same institution and participated in either a DEU clinical teaching model or a TC model for their 16-week (120 hours) senior clinical experience (N = 137: DEU = 83 and TC [non-DEU] = 54). The response rate was 28%, and most of the participants (63%) had graduated between 2015 and 2018. Most respondents were White women (90.2%). Ages of participants ranged from 21 to 51 years old, with the mean age of 25.27 for those alumni with DEU experience and a mean of 26.65 for alumni with TC experience.
NGNs were asked to reflect on their experiences as NGNs and assess their comfort and confidence as they transitioned into their new role. Participants rated comfort and confidence levels in relation to 23 subscales of professional nursing practice, including support, patient safety, communication, leadership, and professional satisfaction. Statistically significant differences between the two groups indicated that NGNs with DEU experience felt significantly more comfortable overall with suggesting changes to the nursing plan of care, whereas those with TC training experienced far more discomfort overall (χ2 = 8.303, p < .04; see Figure 1). Furthermore, those from the DEU program strongly agreed in greater proportion that they felt more supported by nurses on the unit (χ2 = 5.808, p < .016; see Figure 2.)
Findings that were clinically, though not statistically, significant indicated that NGNs with DEU experience reported feeling more comfortable and confident than NGNs with TC experience in communicating with physicians, delegating, prioritizing, making suggestions, and organizing and indicated that they would not harm their patients due to lack of knowledge or experience. Note, however, that fewer than half of both groups reported lacking comfort and confidence in this area (see Figure 3).
Qualitative Data From NGNs
The final question of the electronic survey asked NGNs to share comments or concerns they experienced or were experiencing in their first position as NGNs. Patterns identified within responses from NGNs with DEU experience (N = 83) indicated that those with DEU experience were likely to cite the support the clinical teaching model provided for managing the complexities of the floor. One alumnus wrote, “The DEU program provided me with confidence, skills, critical thinking opportunities, and time to reflect and build a solid nursing foundation before even entering my first job as a nurse…the DEU program definitely made my transition to an NGN easier and enjoyable.” Another alumnus wrote, “I will always be an advocate for DEU and I do believe that it played a role in making my transition easier. Although I was stressed about the job, I had the upper hand, as I was already familiar with the charting system, floor-specific duties and common diagnoses and treatments for patients treated on my floor…I would choose DEU over traditional clinical any day!” Complaints included high nurse/patient ratios, time management challenges, the wide variation in preceptors, and the shortening of orientation due to higher expectations of former DEU students and/or staff shortages. Patterns identified within comments made by alumni with TC experience (N = 54) echoed concerns about variations in preceptor quality, support, nurse/patient ratios, and time management challenges. On the positive side, some noted that the variations in their early assignments underpinned learning curves that made their transition manageable. One alumnus wrote, “My first position as nurse was a great learning experience and I had great preceptors who taught me time management and exposed me to a multitude of different patient scenarios that were not often seen which helped develop a strong foundation for my nursing skills.” And another wrote, “It was overwhelming at first, but with support from coworkers, management, preceptors and educators it was manageable.” No positive comments were made about their clinical experience during their education program making transition easier. Notably, several references to bullying were made by those with TC experience. As a final note, comments were made by both DEU and TC NGNs about difficulties with electronic health records.
Qualitative Data From Interviews With Nurse Mangers
Nurse managers (N = 9; N = 3 nurse managers participated in DEU units, N = 6 nurse managers participated in TC units) defined competency as comfort communicating with patients, safe practice, being organized, prioritization, caring, compassion, confidence, knowledgeability, empathy, preparedness, strong clinical skills, critical thinking, and experience. Themes that were identified in regard to qualities that contribute to a new nurse’s successful transition into practice included confidence, empathy, safe practice, willingness to learn, being caring, knowledgeability, preparedness, open mindedness, and possessing the ability to think critically. One nurse manager was quoted as saying, “New graduate nurses need confidence; [they need to be] willing to go the extra mile, willing to learn” and “communication is basically half the battle.” Themes identified in terms of differences between NGNs with and without DEU experience included being more confident and comfortable in the professional environment; being more prepared and ready to practice; possessing stronger leadership skills, including critical thinking skills, delegation, comfort initiating changes to nursing care plans, and communicating and collaborating with patients, families, unit staff and physicians; and easier transition to practice and decrease in orientation time. One manager stated that, during job interviews, NGNs with DEU experience were better able to “respond appropriately to more difficult clinical case scenarios [and] talk about experiences they had from DEU clinical more holistically, including talking about the socioeconomic part [of patient care] and teaching.” The same manager added that, during interviews, NGNs are expected to confidently walk into a patient’s room, complete a comprehensive head-to-toe assessment, and apply critical thinking to look for “disconnects.” The manager reported that “new graduate nurses from the DEU program were better able to articulate this task.” Another nurse manager said, “The DEU new grads are more clinically prepared to care for patients; it takes less time to get them comfortable on the floor. New graduates are awkward; DEU new grads are quicker to train, they are able to be taken off orientation quicker…. They are more focused on the next step for care—critical thinking; they also focus more on delegation to nursing assistant than non-DEU new graduates; non-DEU do not delegate well…. New graduates with DEU experience are more focused on care, they look at patients in a more holistic way, they are more autonomous, more verbal and engaged in rounds.” Another nurse manager was quoted as saying, “It’s like they are 2 months ahead of their non-DEU peers.”
This is the first known mixed-method study to examine the impact of a DEU on NGNs’ transition to practice. Although these findings highlight the positive impact of the DEU on preparing NGNs for practice, it is important to note that, overall, over 30% of NGNs from both groups identified as feeling “uncomfortable” and not confident communicating with physicians, asking for help, organizing and managing their time, and, most concerning, having the knowledge and skills to not harm a patient. These concerning findings align with current literature that identifies NGNs as lacking confidence and having difficulty transitioning into their professional roles, which can pose risks to patient safety (Benner, 2010; Brown & Crookes, 2016; Huston et al., 2018; IOM, 2010).
NGNs from both the DEU and TC teaching models commented on challenging nursing ratios and the deleterious effects of variations and inconsistency in preceptor qualities. NGNs with TC experiences commented on the help they received from preceptors and floor nurses in making the transition but no comments were made on the educational program, whereas DEU NGNs commented on their experiences in the DEU as helpful or even vital.
The DEU clinical teaching education model was identified by alumni as being supportive in building confidence and developing the clinical and leadership skills needed to ease the transition from student to practicing nurse. In addition, the DEU was recognized for supporting critical thinking and interdisciplinary communication. These findings are consistent with the literature evaluating DEUs, which indicates that students’ critical thinking and clinical judgment increase in response to the constant interactions and conversations with CIs during their DEU experience (Mulready-Shick et al., 2013; Schecter et al., 2017). Findings are similar to other studies identifying DEUs as superior to TCs in engaging students in clinical learning environments and enhancing their abilities to apply learned classroom theory to real-world practice (Jayasekara et al., 2018; Mulready-Shick et al., 2013; Schecter et al., 2017). Nurse managers observed that NGNs with DEU experience were more engaged and eager to learn and overall better prepared for contemporary practice than those without. Furthermore, nurse managers identified that the NGNs with DEU experience had often completed orientation by 10 weeks instead of the 12 usually expected for NGNs without DEU experience.
A limitation of this study is that it was conducted at only one BSN program with a history of implementing DEUs at one major medical center. In addition, retrospective self-reports are vulnerable to bias and lack of specific recall. Another limitation of this study is the challenge of quantifying NGNs’ experiences as they transition from student to practicing professional.
Recommendations for future research include identifying and regularizing innovative strategies to support NGNs’ transition into practice. Further exploration of the impact of the DEU clinical teaching model on preparing NGNs for practice should be undertaken, developing additional instruments that apply benchmarks for successful transition based on the needs of the “end users”—healthcare organizations, healthcare teams, and patients—that might better assess the costs and benefits for implementing DEUs. As DEUs proliferate, the development of measurement tools to better assess clinical teaching models on NGNs’ transition into practice is essential.
NGNs experience stress and difficulty transitioning from student to practicing professional. Increased stress affects successful transition into practice, thereby negatively affecting new graduate retention rates, increasing attrition and healthcare costs, and compromising patient safety. Furthermore, literature suggests that lack of preparation is a common source of NGNs’ stress and may result in low job satisfaction, impeded professional development, and decreased commitment to the profession. Although responsibilities of NGNs have changed dramatically over the past 30 years, clinical teaching models have not kept pace with these changes. The findings of this study identify the DEU as a positive clinical learning environment where future nurses are supported with the development of necessary competencies, thus easing the transition from student to professional nurse. Academic and practice organizations are urged to collaborate to align curriculum and efforts to address the difficulties NGNs experience as they transition from student to practicing professional. The collective wisdom and collaborative efforts of academic and professional leaders in nursing can potentially serve as a powerful catalyst for improvement in the preparation of NGNs for practice.
The authors acknowledge Rose Girgenti, MA, RN-BC and Frances Paulison, MSN, RN from St. Joseph’s University Medical Center in Paterson, NJ.
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