New graduate nurse readiness for practice is a shared goal of academic programs and employers. Educators, and the nurses with whom they partner in the academic-clinical setting, often express concern that students are not adequately prepared for safe patient care. Evidence exists that new graduate nurses do not meet competency expectations with regard to critical thinking and clinical judgment,1,2 planning and prioritizing care,2,3 independence and competent performance of nursing skills,1,4-6 and effective recognition and communication of patient needs and status changes.4,5,7 There are also differences in perception of readiness for practice between nurses, nurse educators, new graduate nurses, and nursing administrators.1,8
Inadequately prepared nurses entering into practice carry risk to patient safety, quality of nursing care, and retention in nursing. The Robert Wood Johnson Foundation9 identified that as many as 20% of RNs leave the profession within the first year of nursing and this increases to as many as 33% in the next 3 years. The US Bureau of Labor Statistics10 projects that the need for RNs will increase by 15% by 2026. With the demand for nurses on the rise and the retention of new graduate nurses a concern, it is vital that an understanding of influential factors be identified. According to the literature, new graduate nurses identify that a lack of clinical confidence inhibits successful transition into professional practice.11 Clinical confidence is vital to the provision of quality care for complex patients.12,13 Clinical confidence, aligned with nursing knowledge, skills, and professional attributes, is an essential component to the development of clinical competence.12 Therefore, exploring preceptor perceptions of student confidence and competence through readiness for practice can inform teaching strategies and clinical-academic partnerships both before and after the first year of practice.11
New graduate nurses are typically expected to be able to immediately apply the information learned during their nursing education into clinical practice.1,14 An integrative review by Missen et al5 explored RNs' perceptions of new graduate nurse clinical competence. Experienced nurses reported that the areas of concern for new graduate nurses included clinical/technical skills and critical thinking. This is consistent with the findings of Hickey,1 who reported that 63% of preceptors thought that new graduate nurses needed more assistance with the performance of technical skills. Wolff et al6 (p189) found that experienced nurses viewed new graduate readiness as the ability to “hit the floor running.” Furthermore, Romyn et al15 found that new and experienced nurses perceived readiness for practice as the ability to provide competent, unsupervised care as the new nurse begins his/her career. There is no universally established set of expectations that define new graduate readiness for practice.
Preparing students for entry into practice is a team effort. Nursing programs rely on partnerships with practicing nurses throughout the nursing program to create optimal learning experiences for students and promote readiness for practice. A critical time in this partnership is the final phase of the nursing program, often termed a preceptorship or capstone practicum experience. During this time, the nursing student works one-on-one with a designated preceptor for an intensive clinical experience. The preceptor provides direct supervision and feedback to the student while partnering with nursing faculty to guide and facilitate the learning process. Hickey14 indicated that the preceptor model of instruction is particularly effective in assisting with the transition to practice. Although preceptors are in a position to identify nursing students who are adequately prepared for the clinical setting, preceptors also must have a realistic expectation of what constitutes adequate preparation for practice.16 Preceptors' perceptions of student readiness during the final phase of clinical education are valuable to determine whether nursing students are ready for practice.
The variation in the perceptions of readiness for practice was a key motivator for exploring student learning and professional development needs. Building on the literature, our study is focused not on newly hired graduates but rather on students in their last semester of the prelicensure program to assess student progress toward readiness for practice. The purpose of this study was to determine the strengths and weaknesses of senior-level nursing students related to readiness for practice 1 term before graduation.
Design and Sample
This was a descriptive, exploratory study conducted at a private Midwestern university. The sample consisted of students enrolled in a baccalaureate nursing program. In total, 15 student cohorts (N = 856) were eligible for inclusion into this study. The study took place between August 2011 and May 2016. After approval from the institutional review board, nurse preceptors were asked to participate. Nurse preceptors who evaluated the students in our program are all baccalaureate-prepared with at least 2 years of nursing experience.
The Readiness for Practice survey tool was developed to assess nurse preceptor perceptions of senior level students' readiness for practice. The first steps in development included faculty assessment of student clinical performance from recent years, a review of feedback from clinical partner evaluations, and an exploration of the literature regarding new graduate nurses' readiness for practice. Through these efforts, a list of priority nursing knowledge areas, competencies, professional attributes, and general expectations for new graduates was created. The 3 domains of learning framework, affective, psychomotor, and cognitive, were used to organize the tool and allow for both overall assessment of readiness for practice as well as assessment of affective, psychomotor, and cognitive aspects of the nursing role. This framework aligns with the Quality and Safety Education in Nursing competencies essential for quality and safe nursing practice.17 Content validity was established using nurses in 7 different health care settings across the United States.
The final tool contained 33 items evaluated on a 5-point Likert scale. A rating of 1 indicates that the student is not meeting the preceptor's expectations, a rating of 3 indicates that the student is meeting expectations, and a rating of 5 indicates that the student is exceeding the preceptor's expectations. Of the 33 items, 29 evaluated competencies and professional attributes categorized in the affective (11 items), psychomotor (7 items), and cognitive (11 items) domains. The final 4 items of this tool evaluated the student's overall confidence, competence, ability to provide safe care, and readiness for the preceptorship experience.
Cronbach's α was calculated for each domain. The cognitive domain had a Cronbach's α of .955 and included items that evaluated the student's knowledge of fundamental course work including pharmacology and pathophysiology. The psychomotor domain had a Cronbach's α of .936 and included items that addressed comprehensive processes such as prioritization and time management. The affective domain had a Cronbach's α of .952 and included items that addressed communication and the delivery of culturally competent care.
The Readiness for Practice survey tool was emailed to the nurse preceptors during the first 2 weeks of the preceptorship. All data were gathered anonymously, stored in a password-protected database, and not used for individual student evaluation. Data were analyzed using SPSS version 25 (IBM Corp, Armonk, NY).
A total of 569 preceptor responses were recorded (66% response rate). The affective domain items had the highest mean of 4.13. The 4 items measuring the students' general/overall readiness had a mean of 4.03. The mean for all items in the cognitive domain was 3.86, and the mean for all items in the psychomotor domain was 3.83. A summary of the highest and lowest scoring survey items is in the Table. Full results for all items across domains are shown in the Table, Supplemental Digital Content 1, http://links.lww.com/NE/A475.
The items within the affective domain consistently scored highest of the 3 domains. The top 5 items within the affective domain were as follows: performs as a team player (mean [SD], 4.32 [0.762]), professional and ethical behavior (mean [SD], 4.29 [0.764]), taking responsibility for their practice (mean [SD], 4.19 [0.833]), bedside presence (mean [SD], 4.19 [0.850]), and delivering culturally competent care (mean [SD], 4.15 [0.743]). Within the cognitive domain, the 5 highest scoring items were questions appropriately (mean [SD], 4.23 [0.817]), documentation of nursing care (mean [SD], 4.04 [0.861]), knowledge of how to access patient data (mean [SD], 3.94 [0.823]), knowledge of pathophysiology (mean [SD], 3.86 [0.838]), and accesses resources to support decision making for patient care (mean [SD], 3.85 [0.802]).
Although the psychomotor domain had the lowest mean score of the 3 domains, the 5 items with the highest scores were basic technical skill performance (mean [SD], 4.07 [0.863]), medication administration (mean [SD], 4.06 [0.852]), assessment skills (head to toe physical assessment) (mean [SD], 3.96 [0.823]), complex technical skill performance (mean [SD], 3.77 [0.920]), and management of multiple or complex patients (mean [SD], 3.67 [0.931]). Finally, of the items that measured general/overall readiness, the highest scored items were student provides safe patient care (mean [SD], 4.16 [0.805]) and student's readiness for the preceptorship experience (mean [SD], 4.19 [0.880]).
Nine of the 10 lowest mean scores were items identified as being within the cognitive and psychomotor domains. The lowest item within the psychomotor domain was time management skills (mean [SD], 3.62 [0.982]). The item with the lowest mean score within the cognitive domain was knowledge of laboratory values and implications (mean [SD], 3.71 [0.851]), and the lowest rated item in the affective domain was communication with other disciplines (mean [SD], 3.82 [0.864]). Of the 4 items on general/overall readiness, the student's overall confidence level in the clinical setting had the overall lowest mean score (mean [SD], 3.82[0.963]), followed by the student's overall competence level in the clinical setting (mean [SD], 3.94 [0.866]).
Discussion and Implications for Nurse Educators
There were several areas of strength found in the affective domain items of the tool. These strengths align with the ethics and values of the nursing profession,12 as well as the university mission. The faculty view these findings as a positive reflection of the program and the understanding that nursing is about not only scientific knowledge but also compassion and professionalism. Evidence of these strengths supports continuation of mission-based curricular design and teaching strategies, such as reflective journaling, and values- and ethics-based courses in the curriculum.
Within the cognitive domain, knowledge of pharmacology (mean [SD], 3.72 [0.896]) was one of the lower scoring items in the study. A deficit in pharmacology knowledge is common in both nursing students and practicing nurses.18-20 This deficit is of great concern because of the amount of time most nurses engage with medications in practice.19 Pharmacology knowledge is vital for safe quality nursing care and has been shown to be a factor in predicting pass rates on the NCLEX.21 Content such as pharmacology needs to be taught and reinforced in meaningful ways throughout the nursing program.19,20 To strengthen knowledge of pharmacology, faculty in our program have added more in-depth pharmacological analysis in clinical paperwork and conferences. The nurses with whom students work in the clinical setting throughout the program are also being oriented with an intentional focus on promoting student knowledge and safety related to pharmacology.
Ability to see the big picture (mean [SD], 3.74 [0.861]), differentiating pertinent from nonpertinent data (mean [SD], 3.77 [0.858]), and knowledge of pathophysiology (mean [SD], 3.86 [0.838]) were other concerning low scoring items in the cognitive domain. These findings provide nurse educators with evidence for incorporating more applicationfocused teaching strategies in the nursing program. Such strategies can support students' application of the relationship between content and nursing care priorities, help them see the big picture, and make appropriate decisions in patient care.
The psychomotor domain was consistently the lowest scoring domain (mean, 3.83) in the study. Low scoring items in this domain included complex technical skills performance (mean [SD], 3.77 [0.920]), time management skills (mean [SD], 3.62 [0.982]), prioritization of interventions (mean [SD], 3.65 [0.910]), and management of multiple or complex patients (mean [SD], 3.67 [0.931]). These scores were particularly concerning because these competencies were the primary focus of the practicum experience immediately before this assessment. However, these findings are consistent with Kumm et al's2 study, which found senior students to have low scores in critical thinking, prioritization, and management of multiple responsibilities at the beginning of the capstone clinical experience. These data provide evidence for nurse educators to further explore the frequency and quality of student exposure to skills in simulation laboratory experiences and in the clinical setting. Educators also need to negotiate with clinical partners to increase hands-on experiences and enhance student exposure to the psychomotor skills and decision making needed in professional nursing practice.12,22
The evidence from this study, along with data from course examinations and NCLEX performance, can be used to inform curricular decisions throughout the program. Educators should use these data to support collaboration with clinical partners to develop shared expectations of students and optimal learning experiences that promote greater readiness for practice and safe patient care.
Limitations and Areas for Further Research
Generalizability of the findings is limited because there is no standardized set of nurse expectations for student clinical performance. Nurses have their own expectations based on personal experiences and perspectives on nursing care and education.8 However, in future studies, nurse preceptor responses could be tracked to assess for interrater reliability. This study is also limited in that it involves a single-school, thus multisite application of the tool in both baccalaureate and associate degree nursing programs would provide more data to influence teaching strategies and design of clinical learning experiences.
Because of the variability in nurse perceptions, some of the survey items can be interpreted differently by nurses. For example, the item knowledge of pharmacology is meant to be interpreted as knowledge of pharmacokinetics; however, some preceptors might have interpreted this as knowledge of medication administration principles or dosage calculation. Similarly, specific criteria were not defined for each rating category on the Likert-type scale, thus allowing variability in nurse responses and evaluation of the student. The variability in individual interpretation is acknowledged, but this study did not seek to define or establish a common set of definitions or nurse expectations. However, this could be an opportunity for further research.
Nurse educators have an important obligation to ensure that their students are progressing toward readiness for practice. This study sought to assess students' readiness for practice as perceived by nurse preceptors 1 term before graduation and entry into practice. Nurses are important stakeholders in the professional formation of the future workforce. Input from the nurse preceptors at the beginning of the capstone practicum contributed valuable evidence regarding student strengths and weaknesses before they leave the nursing program. The data also provide evidence for enhancing teaching strategies and strengthening academic-clinical partnerships to move students toward readiness for practice.
The authors thank Drs Joan Lappe and Linda Lazure, Creighton University College of Nursing.
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