Nursing The Future 2.0

Reimagining New Graduate Transition in the COVID-19 Era (Part II)

Abstract

For newly graduated nurses (NGNs), the characteristically challenging and dynamic period of transition from student to professional practitioner is being further strained by global crises and the uncertainty and insecurity they motivate, health care systems and institutional restructuring, and extreme workload burdens. A novel approach to aiding the transition of NGNs is detailed in this article, culminating in the offering of an inclusive framework of potential strategies aimed at supporting NGNs and those who lead, manage, and educate them. This approach outlines strategies of support deliverable by both centralized and local means and acknowledging contemporary needs such as workload burdens and generationally-sensitive employee needs. Nursing The Future is a platform that uniquely situates an evidence-based, grassroots-driven response to the needs of NGNs, while encouraging collaborative partnering of health care institutions with governmental, professional, and regional advanced education bodies. This is the second article in a 2-part series that builds on the historical and developmental intents of Nursing The Future as an organization and outlines how evidence-informed, creative, and affordable grassroots-driven supports may be offered to NGNs for the purpose of sustaining and advancing our future nurse professionals.

NURSING THE FUTURE 2.0

In March of 2020, the global landscape of health care was drastically, and it would appear enduringly, altered. With the change brought about by a global pandemic came a dramatic surge in intensity, uncertainty, and instability within both the culture and context of nursing practice. It seemed that more than ever, the sustainability of quality health care in Canada was dependent upon the collective ability of nurses to optimize their work environment and our ability to empower the newest professionals to deliver a high standard of care to individuals at the most vulnerable moments of their lives. Due largely to the health care demands resulting from COVID-19, and arguably the toll taken on senior practicing nurses that played out in unprecedented rates of attrition, the need for newly graduated nurses (NGNs) escalated in the years following the pandemic. These demands have served as a catalyst for the current global health human resource crisis.

In responding to this crisis, there is little doubt that countries will need to continue to work with relative urgency to ensure the optimal preparation, workplace integration, and retention of the newest members of the nursing profession. To actualize this agenda, they will need concrete measures to support and protect novice practitioners who consider their disrupted education and the stressors in the contemporary nursing workplace to be impeding their practice and professional development. The collective decisions made regarding the nursing workforce over the coming years may be the tipping point in our essential task of building (or some might argue “rebuilding”) a highly functioning and resilient workforce.

In the United States, it has been reported that the mitigation of a one percentage change in RN employee turnover saves a hospital US $262 300 yearly.¹ The anticipated influx of new professionals needed to replace an aging and exhausted nursing workforce, and the now unprecedented job stress that is being experienced by new recruits in hospital settings, should alarm both education and health service sectors. Unless steps are taken to recognize, understand, and provide support for the resolution of the issues inherent in the traumatic and stressful socialization of NGNs to professional practice, we are in danger of not being able to replenish and rejuvenate this critical component of our health care workforce during this unprecedented care crisis and beyond. Nursing The Future 2.0 (NTF) evolved out of this urgent call for support in balancing the stark realities of practice presented here with the ongoing advancement of theoretical, ethical, and practice foundations of nursing as a discipline. By supporting NGNs in their social integration as well as their practical and theoretical application, and by uniting them with the senior nurses upon whom the health care system has traditionally relied, we can reasonably expect to optimize their decision-making, increase the quality of their clinical judgments, and foster a quality workplace culture. It is equally easonable to assume that these actions will favorably influence the NGNs work satisfaction and ultimately enhance the clinical outcomes of the patients they care for. The creation, implementation, and evaluation of transition-specific programs, policies, and practices that seek to recruit, retain, and rejuvenate our health care workforce in Canada depend on linkages between research, policy, and a current and accurate profile of the issues facing practicing NGNs in this country.

Canada is recognized as a leader of innovative global health care initiatives. In collaboration with partners in postsecondary education, the health care service industry, professional nursing organizations and associations, unions, and ministries, provincial communities are charged with understanding nursing needs as they work to replenish and revitalize their nursing workforce. Understanding the challenges faced by NGNs as they make the transition to professional practice, and supporting programs that can optimize a collaborative educational, governmental, and industry-centered response to these issues, will assist provinces to recruit and retain energized and motivated young professional nurses in Canada. In support of this mandate, the Canadian Nurses Association's document, titled Toward 2020: Vision for Nursing, emphasized the need for the nursing profession to take control of its future, not react to it.² The vision and mandate of the NTF support platform epitomize Michael Villeneuve's assertion that “if nurses aren't building their future, someone else surely will.” Further to this, in a position statement released March 2020, the Canadian Association of Schools of Nursing clearly stated that efforts to optimize entry to practice for NGNs while supporting the delivery of health care services during this challenging time were a priority. The current crisis places NGNs entering practice for the first time in an unprecedentedly unstable position.³ The Canadian health care system is experiencing tremendous tension and, in places, it is on the verge of being entirely overwhelmed. As a result of evolving world crises (ie, political, health, climate, and economic systems strain), our existing nurses are being excessively burdened not only by stressed workplaces but equally also by the daily witnessing of trauma in both their professional and personal lives.^4–7 It is reasonable to assume that these stressors will tax those nurses as they seek to support NGNs entering the practice context.

An urgent collective approach to supporting NGNs in the workplace that includes the health care sector, nursing education, government, and the entire professional nursing community is required. The creation, implementation, and evaluation of a national transition support program are the gateway to the capacity of our provinces and territories to recruit, retain, and rejuvenate their health care workforces. Actualizing this mandate requires that we form deep and broad linkages between research, policy, and strategy that represent a current and accurate profile of the issues facing practicing NGNs in this country. This current tragedy has the potential to be a catalyst for positive change in our health care community.

Commencing in July 2021, Duchscher and a team of nurses from across Canada developed the current version of NTF (www.nursingthefuture.ca) as a Web-based platform that was intended to serve as: a support network for NGNs moving into professional practice for the first time; a knowledge-generating and initiative-sharing platform about NGN professional role transition (PRT) for health care educators and employers; and a source of information that can assist in our understanding of practice patterns and workplace issues being faced by NGNs and their senior nursing colleagues. Creating this network occurred in close consultation with NGNs and health care practice partners across the country (eg, health care regions, educational institutions, ministries of health, professional organizations, and unions) with the intent to harness the creativity, ingenuity, and commitment to excellence that exist throughout our national nursing community. The comprehensive array of strategies served to assist NGNs with their social integration into the workplace, supported the practical and theoretical application of their knowledge in new clinical situations, united them with their senior nursing mentors, and offered leadership opportunities for nurses across this country. The outcome of an improvement in workplace culture and the fostering of a collaborative ethos amongst our nursing family is the optimization of decision-making in practice, an increase in the quality of the clinical judgments that are the cornerstone of excellent care, and a workplace that welcomes and unifies its practitioners. While long-term funding for the ongoing efforts of NTF has not yet been secured, the proposed actions of this support platform have demonstrated a significant influence on both NGNs and their senior colleagues. This said, the intent of this article is to share the platform strategies so that all institutions and health regions can enact similar programs with the potential to optimize professional integration of all nurses, increase work satisfaction, unite the nursing profession, and positively impact the health outcomes of our citizens.

The foundational elements of this initiative are as follows:

Support for NGNS in all sectors and practice contexts include, but are not limited to, hospitals, long-term care settings, and rural and remote practice settings:

• NTF is built upon an inclusive, bilingual Web-based platform and framed by contemporary evidence related to the PRT of the NGN;
• Multiple strategies target the dissemination of knowledge related to PRT and the support of mentoring relationships between NGNs and their senior practice partners in acute care, long-term care, community, home care, and public health contexts;
1. Virtual and face-to-face chats offer connections, problem-solving, and professional collaborations with experienced practitioners and more senior NGNs;
2. “Normalization” of the transition experience is facilitated through information sessions on the Stages of Transition and Transition Shock;
3. Video- and text-based information on coping highlights both the personal and professional (patient/client/family/community) health and social struggles being experienced in our world secondary to the suffering and isolation of individuals and families in our communities; and
4. The acknowledgment of historical colonial trespasses and crimes committed against Indigenous communities, as well as current inequity experienced by those in particularly rural settings, has informed resource decisions, consultations, content, and goals across NTF. Strength-based approaches to supports for Indigenous NGNs returning to, and supporting, their home communities are facilitated by forging strong linkages between local and regional Elders and leaders, Indigenous professional groups (eg, Canadian Indigenous Nurses Association), and Indigenous NGNs.

Building and strengthening of the larger community of nursing includes licensed/registered practical, registered, and registered psychiatric nurses:

• Strategies and initiatives within the NTF platform consider all areas of practice (urban/acute care/community/public health/rural/remote); and
• NTF includes all nursing scopes and represents this broad demographic on the Nursing the Future Project Team, embracing all scopes of practice for inclusion on local, regional, and strategy-specific consultation teams;

Health care sector employers, nursing educational institutions, ministries of health and ministries of advanced education, skills, and training are key partners in any strategy that addresses preparatory education and workforce integration and retention of the health care workforce:

• Leaders at various levels (local, regional, provincial, territorial, and national) were invited to participate in consultation sessions over the course of the development of NTF and are included in ongoing strategy and initiative evolution; and
• Ongoing and continuous feedback loops are infused into communication coming into and going out of NTF (eg, NTF Newsletter Monthly Distribution to NTF Members/Provincial and Regional Employment Boards/Student and NGN Chat Platforms/Educational Podcasts on “Preparing for Your Transition to Professional Practice”).

A strong nursing and health care workforce requires ongoing attention to the development and nurturing of professional competence, advanced practice, and leadership potential in NGNs:

• Various avenues for facilitating an interface of NGNs with their senior nursing leaders are integrated into NTF strategies and approaches (eg, interviews with more senior NGNs, senior nursing partners and nursing leaders, frameworks for provinces and regions to establish their own New Graduate Transition Facilitation Networks, and a Virtual Conference on New Graduate Transition); and
• Working alongside, and learning from experienced clinical, academic, and health care leaders, NGNs are encouraged and facilitated to expand their professional development to include advanced skills preparation and education.

Driven by emerging data, current workplace needs, and previous iterations of NTF, Duchscher developed strategies aimed at meeting the diverse needs of NGNs (Table).

Table. - Strategies for Successful Transition of Newly Graduated Nurses

Strategy	Description
Transition Theory	Duchscher's Transition Shock model and Stages of Transition theory are detailed on these pages—numerous documents offer students, NGNs, and their supporters insight into, and frameworks for, application and implementation of the most current knowledge of transition from student to professional nurse. Non-nursing transition theorists are also featured.
The Greenhouse	Established as both a virtual strategy and a face-to-face strategy, The Greenhouse offers multiple avenues of leadership capacity building, including activities for: (1) NGNs (<1 y of practice) who are not necessarily ready for formal leadership positions but who are looking to increase their skills related to relationship building, clinical confidence, professional networking, nursing advocacy, or crisis communication; (2) recently graduated nurses (RGNs) (1-2 y of practice) who are exploring ways to enhance their knowledge-sharing capacity through various approaches to scholarship that include discovery (research), evidence integration and application, or teaching; considering clinical leadership positions like taking on charge positions; or considering clinical advancement opportunities such as patient care coordination; (3) graduates interested in advancing their professional knowledge in areas such as specialty practice, nursing education, graduate studies, clinical research, and/or formal nursing leadership roles.
	The Greenhouse incorporates 3 platforms: (1) Building Capacity: The Road to Leadership fosters grassroots leadership conversations between NGNs, RGNs and senior nursing leaders; (2) Leaning In consists of a series of interviews and Master Classes from nursing leaders. The goal of these sessions is to advance research, innovation, and grassroots practice initiatives through knowledge translation and dissemination, professional mentorship, and leadership skill building; (3) The Incubator consists of face-to-face workshops addressing and evolving the leadership needs of NGNs and RGNs. The Incubator was created to occur as a PRE-CONFERENCE Workshop at the Workplace Integration for New Nurses (WINN)/NTF Annual Conference.
Question Period	Hundreds of questions are answered related to preparing for and then making the initial entry into professional practice. Both grassroots- and research-inspired perspectives target students, NGNs, and NGN supporters.
The Interview	Nurses share their reflections on and stories about practicing nursing today in a video format—what nursing means, what makes nursing practice unique, what challenges they overcame and how. Health care topics important to NGNs are the focus.
Speaker Series	Leaders in diverse fields share their perspectives on the issues and challenges of nursing and health care today. A lens on how the issues impact NGN practice and how new professionals might influence the issues is offered.
Book Club	A monthly archived selection of books on a host of provocative, contemporary nursing and health care issues is featured, including 1:1 interviews with renowned authors.
The Podcast	Audio interviews with a multitude of guests on all subjects impacting nursing students and NGNs in practice are featured here. With topics ranging from coping with the stress of transition and remaining resilient in a health care system under pressure to understanding the stages of PRT, recognizing and dealing with moral distress and compassion fatigue, combating bullying in the workplace, or learning how to structure communication with physicians, The Podcast is diverse and comprehensive.
Nursing Excellence Awards	Five awards celebrate NGNs, frontline nurses, educators, and nurse leaders positively impacting the nursing profession and the health care system. The Strength in the Storm Award is conferred upon a new graduate, frontline nurse, senior nurse, educator or nurse leader who has consistently overcome disruption, chaos and turmoil during a global pandemic affecting both personal and professional aspects of their lives. Called upon to make sacrifice after sacrifice, this award recognizes the contribution, leadership and steady hand of nurses in Canada, who are stabilizing forces in their families, communities and profession. The Teaching Excellence Award recognizes the substantial contributions of committed, engaging, and innovative educators in nursing education across the country. This award is granted to an educator or team of educators who make a broad range of contributions to the nursing education community including, but not limited to, the creation of new courses and programs, devising and implementing innovative strategies for instruction, conducting research on teaching and learning issues and other important work that occurs inside and outside the classroom. The New Graduate Excellence Award is offered to a new graduate (in professional nursing practice < 1 year) who displays humility and trustworthiness, elevating the level of dialogue in conversations about nursing, leadership and change. This individual has displayed evidence of courage and compassion, volunteers and contributes to community and professional initiatives. They have displayed exemplar growth in leadership over time and have the potential to positively impacts the nursing profession. The Torch Award acknowledges leadership in new graduate issues, and is awarded to a nurse leader, researcher, educator or frontline practitioner who recognizes the complexity of the transition experience, promotes initiatives aimed at supporting the healthy integration of new grads in professional practice settings, researches new graduate issues with the goal of advancing the knowledge base in this area of scholarship, evaluates new graduate initiatives with the goal of improving them for the future, implements supportive networks for the benefit of the new graduate population. Finally, the Odyssey Award goes to an individual who has played an essential role in the development of a new graduate nurse(s) in the workplace. It recognizes the importance of experienced colleagues in facilitating a healthy professional role transition for new nurses. The award is preferential to applicants who consistently demonstrate NTF's values in the workplace.
CONNECT	Synchronous virtual sessions attended in the hundreds feature educational content on contemporary issues facing students and NGNs in practice—discussion and debate are encouraged, and the issues discussed are immediately impactive to NGNs transitioning into practice (ie, NCLEX preparation, dealing with horizontal aggression from colleagues, time management).
Blog	Some people like to listen, some are visual, while others like to read. These short bursts of text introduce NGNs and students to featured scholars from around the world who are experts on nursing and health care.
Newsletter	This quarterly publication features editorials on a variety of topics (regular columns such as “‘Let's Talk Transition” plus a variety of other guest editorials that speak to contemporary subjects—ie, Indigenous Nurses and the TRC). Each newsletter features a senior nurse (i.e., “Mentor Profile”) and an NGN (“TrailBlazer”) from across Canada, drawing attention to the importance of mentorship and profiling the outstanding work being done by the newest members of our profession.
International Conference on Workplace Integration for New Nurses (WINN)	This annual conference hosts an international audience for the purpose of sharing research, innovation, and capacity-building initiatives specific to the education, orientation, transition, integration, and stabilization of NGNs in the workforce. Integrated into the annual conference platform are specific workshops that discuss topics exclusive to students and NGNs entering practice for the first time. A New Graduate Planning Committee consisting of NTF leaders, senior students and NGNs determines both content and format for the NGN-specific knowledge dissemination.
On Call	NGN Crisis Line for general advice and counsel.
Regional/National/International Resources	Web pages with regional resources that include employment opportunities and information about NGN orientation and transition support programs in partnership and regarding health authorities across Canada. NTF also recognizes the unique needs of internationally educated nurses in Canada who constitute approximately 8.4% of the employed nursing workforce.8
Welcome to Our World	This multipronged platform was developed in recognition of the vital nature of mentorship between novice and experienced nurses. Initiatives for this strategy were intended to emphasize support, connection, and collaboration, with the primary goal of embracing our newest professional members, encouraging professional development in and amongst all nurses, and bridging the gap between school and the workplace from social, developmental, and professional perspectives.
Storm Chasers	One of the primary subelements of the Welcome to Our World strategy to support NGNs is a platform for ‘boots on the ground’ (unit/institutionally based) support within the workplace. Working closely with health regions across the country, recent graduates (1-3 y of practice experience) will be selected by their workplaces to undergo a specialized certification program through NTF to advance their knowledge, understanding, and application of transition theory, conflict resolution, and crisis management skills. These Storm Chasers will then be called upon to respond to NGNs struggling with transition. Planned as a self-sustaining initiative, the NGNs supported by Storm Chasers will later be offered opportunities to ‘pay it forward’ by becoming Storm Chasers themselves.
Shock Absorbers	The second of the primary subelements in the “Welcome to Our World” support strategy consists of senior nurses (>3 y of experience) offering mentorship to NGNs with the intent to support them through both the precarious ‘transition shock’ period of their transition (2 wk-2 mo postorientation) and mentoring them through their initial transition year. Working closely with health regions across the country, graduate nurses with >3 y of practice experience will be selected by their workplaces to undergo a specialized certification program through NTF to advance their knowledge, understanding, and application of transition theory with a dual focus on both transition shock and the stages of PRT for the NGN. These Shock Absorbers will be paired with NGNs upon hire and will meet regularly with them over the course of their initial transition year to identify and work through the challenges posed by their transition. Unlike the crisis response approach of the Storm Chasers, Shock Absorbers are there to counter the day-to-day stressors of PRT in the NGN. The intent is to reduce the need for Storm Chaser interventions to urgent and emergent issues only and to support NGNs in their long-term professional advancement planning.
Social Media	Platforms currently include Twitter/Facebook/Instagram/Snapchat/LinkedIn and provide opportunities to post PRT information and support ideas for NGNs—decisions on media focus are driven by NGN consultation and empirics from or responses on social media.

Abbreviations: NGN, newly graduated nurse; NTF, Nursing The Future; PRT, professional role transition; RGN, recently graduated nurse; TRC, Truth and Reconciliation Commission of Canada.

CONCLUSION

Challenges to delivering timely and appropriate health care are being experienced worldwide. Although these challenges did not begin with the COVID-19 pandemic, this global health care crisis clearly revealed the fractures and fissures in our system. While transitioning from our precarious and reactive intrapandemic state to one of a new post-COVID-19 reality, identified gaps in our support of practicing nurses must be intentionally and strategically addressed. The trend of highly knowledgeable senior professionals seeking out alternate means of employment to regain their sense of well-being post-COVID-19 will continue to devastate our health human resources and limit our capacity for novice-expert knowledge and professional practice transfer. The reality of workplace trauma, role strain, and moral distress for nurses has been captured in unprecedented levels of burnout and subsequent workplace exiting. While expanding the capacity to optimize individual coping mechanisms when working in the face of human tragedy simply makes sense, the expectation that individual practitioner resilience is or should be the primary response to wide-ranging and pervasive systems issues is dangerously myopic; the challenges we face are multidimensional and require a like response. Despite the existence of supportive transition programs, what remains constant is the time needed for NGNs to engage in the crucial transition period as they develop their professional confidence and capacity. Engaging in an analysis of the dichotomies present in institutional and professional concepts and standards of care is more likely to offer us a diverse and proliferative framework for resolution.

For the current and future betterment of all professional nurses, we argue that an understanding and application of existing and emerging transition theories, consideration of NGN practice and job satisfaction evidence, and evolving insights into the tumultuous context of the contemporary workplace cements the urgent need for formal and standardized PRT programs. NTF has demonstrated how support for the NGN can be approached with fiscal responsibility, cyclical growth, evolution of the new nurses' professional capabilities, and a critical unifying of new and experienced nursing knowledge and skill for optimal outcomes. We suggest that partnerships between government, institutional, professional, regulatory, and other representative groups are required to foster meaningful and engaged dialogue that begins and ends with the evidence on NGN transition and entry to practice challenges. While we witness escalating rates of attrition internationally through the loss of new and seasoned nurses, it is imperative that we focus as fervently on the retention of our nurses as we do on their recruitment.^9–11 NGNs require transition supports to endure current professional challenges, and it can be argued that these can be provided through an evidence-driven, sustainable, and cost-effective means; NTF works.