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How do new BSN nurses perceive their nursing education?

Johanson, Linda S. EdD, RN, CNE

doi: 10.1097/01.NURSE.0000432075.34645.11

Linda S. Johanson is an associate professor and interim department chair in the department of nursing at Appalachian State University in Boone, N.C.

Research Corner is coordinated by Cheryl Dumont, PhD, RN, CRNI, director of nursing research and the vascular access team at Winchester Medical Center in Winchester, Va. Dr. Dumont is also a member of the Nursing2013 editorial board.

The content in this article has received appropriate institutional review board and/or administrative approval for publication.

The author has disclosed that she has no financial relationships related to this article.


Objective: The goal was to determine if new bachelor's of science in nursing (BSN) nurses perceived their education to be relevant for the current demands of the profession. Methods: The design was nonexperimental, descriptive survey research. Data were gathered using a researcher-designed mailed survey. Addresses for survey participants, RNs who had graduated with a BSN within 2 years prior to June 2012, were obtained from the North Carolina State Board of Nursing. Results: This study found that new graduates in the sample perceived their academic preparation to be adequate for transitioning into professional practice; however, new graduates wish they'd had more opportunities to practice clinical skills while in nursing school. Respondents also perceived that some health assessment content included in nursing programs may not typically be useful in entry-level nursing practice. Conclusions: Because a large percentage of the sample perceived they'd had inadequate clinical practice time, new nurses might not feel completely competent with practice-related skills. Employers should take this into consideration when structuring orientation programs. Additionally, the curricula planners for BSN programs might creatively and strategically consider ways to increase or improve the clinical practice opportunities for nursing students.

ALTHOUGH THE NURSING profession is rooted in tradition, healthcare in the United States is experiencing rapid change. The growing use of technology, including telemedicine and electronic medical records, has increased the demand for workers with technological competencies. The trend of downsizing and the continuing healthcare worker shortage means that professionals need to be problem solvers and know how to adapt well.1,2

Nursing education needs to be relevant and produce graduates who transition well into the role of practitioner. Determining the perceptions of graduates is a key element in finding out if these objectives have been met.

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The research question explored was, “What are the perceptions of new BSN graduate nurses regarding the adequacy of their nursing education in preparing them for professional practice?” Was content taught that's rarely or never used in their practice areas? Or, conversely, do they perceive that in practice they needed to know something that wasn't presented well in their educational program?

Giddens, for example, surveyed faculty who teach physical assessment courses and found that most nursing programs teach 81% of 122 physical assessment skills, yet only a small percentage of those skills are commonly used in nursing practice.3

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Literature review

The National Council of State Boards of Nursing regularly conducts research to discern important practice areas for newly licensed nurses, and content in nursing programs typically parallels these suggestions. This information is collected from newly licensed graduate nurses.

Candela and Bowles surveyed new nurses about their perceptions and found mixed results.4 Respondents indicated they felt satisfied overall with their skills for practice, but most perceived that they hadn't had sufficient clinical hours in their curriculums or sufficient preparation in pharmacology.

A descriptive study by Danielson found that new graduates perceived themselves as adequately prepared for the role of care provider but as less prepared for the roles of health informer and adviser.5 New nurses often work in environments requiring complex clinical reasoning skills.6 Nurses who feel unprepared for practice may experience distress and discouragement, which could lead to patient safety concerns, such as when a new nurse hesitates or doesn't act in an emergency, or cause them to abandon the profession altogether.7

The literature indicates that the transitional period is one of changing roles, which may evoke feelings of insecurity that contribute to feeling unprepared. A supportive practice culture is likely to be a major factor in a successful transition.8 In this environment, the guidance and supervision of nurse mentors is expected to enhance transition. Proper socialization, including learning to manage time and stress and to connect theory to practice, may contribute to the perception of preparation for the professional role. According to one study, although new graduates had an initial positive perception about their new position as an RN, this perception deteriorated after only 1 month because of a culture in which they felt excluded and unattended.9

New graduates' perception of being underprepared for practice may impede their successful transition to practice.10 By embracing changes, the nursing educational system can improve its relevance. Hofler synthesized recommendations for nursing education from selected national reports about facilitating the transition to practice. Suggestions included: “Formal internships and residencies, development of clear career paths, core competencies and standards for professional practice, and financial and operational support of ongoing education.”11,12

Helping to prepare new graduates for the stresses associated with the profession can be integrated into the nursing curriculum. For example, a precepted capstone clinical experience that emphasizes applying nursing knowledge and skills is perceived to increase the overall competence of participants.1214 A capstone experience is a culminating senior clinical experience with a nurse preceptor for the purpose of synthesis.

How students are taught is just as important as the content. Qualitative interviews with new graduate nurses revealed a general sense of discontent with a passive teaching strategy.15 Many agree that experiential learning and more practical experiences better prepare nurses for practice.16

After conducting focus group interviews that revealed areas considered to be particularly challenging for RNs, Hartigan also concluded that nursing education should be more reality-based.17 Nurses indicated areas of challenge that included “patient assessment, technical/clinical skills, interactions and communications, and clinical decision-making.” This perceived incongruence between nursing education standards and the realities of professional practice elicited frustration in focus group participants in a study by Wolff et al.18

Some researchers have studied what can be done to remedy this incongruence. Because new graduate nurses may have night duty, one proposal is night duty placement for nursing students.19 After experiencing it, students said they had more time to learn, were able to provide a better continuity of care, and had gained a sense of readiness for practice.

Perceptions about clinical placements of third- and fourth-year nursing students were studied by Hartigan-Rogers.20 Students perceived that the clinical experience was valuable in preparing them for their impending professional role and that direct patient care was more valuable than observational time. The students said that the most relevant clinical experiences exposed them to a wide variety of basic essential skills.

Others have studied new graduate nurses' perceptions of the use of simulation in their nursing programs. Kaddoura found that new graduate nurses perceived that simulation experiences prepared them to bridge the gap between theory and practice and helped them develop critical thinking and leadership skills.21

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The design for this study was nonexperimental, descriptive, survey research. (See Glossary of research terms.) Data were gathered using a researcher-designed mailed survey with self-addressed, stamped return envelopes. The North Carolina Board of Nursing was contacted for the addresses of RNs who had graduated with a BSN within 2 years before June 2012. The study was funded by an internal university grant.

Survey tool. The survey was constructed by the researcher. Face validity was achieved by searching the literature for the most frequently mentioned content areas about nursing education's relevance to practice. These topics were then included in the questionnaire. Content validity was achieved by eliciting expert analysis from four academic nursing colleagues.

All the reviewers concurred that the content areas were comprehensive and related to the research question. A five-point Likert-type scale was used, in which respondents rated 12 items with respect to the perceived adequacy of each in preparing them for practice. Two open-ended items were included to ascertain any omissions in the nursing program of clinical skills perceived as necessary, as well as any skills emphasized that were perceived as rarely or never used.

The survey was examined for reliability using a split one-half technique, which yielded a 0.97 correlation on the Likert scale component. The survey was also distributed to five RNs and one physician to assess it for clarity.

For the respondents in the pilot, the survey took an average of 7 minutes to complete; they reported that they clearly understood it. One person said that an online survey might be preferable. A cover letter sent with the survey explained the purpose of the research, how the respondent was selected, risks versus benefits of participation, assurance of anonymity, and the researcher's contact information. The letter also indicated that submission of the completed survey would serve as consent to participate.

Sample selection. The list of 2,035 new BSN graduates (from the past 2 years) was purchased from the North Carolina Board of Nursing. A systematic random sample of 296 participants was selected, and this sample was mailed the survey, cover letter, and return envelope by regular U.S. Postal Service mail.



Twelve surveys were rejected because of noncurrent addresses, and 58 were returned, yielding a 20% return rate. Each of the survey items was analyzed using descriptive statistics.

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The sample. The mean age of respondents was 27.3 years and the range was 21 to 42. Of the respondents who answered the question about gender, 86% were female and 10% were male. Almost all (94%) were employed full-time in nursing. Two reported part-time employment in nursing and one was unemployed. (See Respondents' employment.)

Survey results. Using a Likert scale of 1 to 5, with 1 being very poor and 5 being excellent, the average rating for each of the 12 items in the survey ranged between 3.89 and 4.40. This indicates that overall, new nurses perceived their academic programs had prepared them well. Understanding and using research findings, preparation for holistic care, and managing the technology associated with practice were rated the lowest; the highest rating average was in physical assessment skills. (See How well prepared for practice are new BSN nurses?)

An open-ended question asked respondents to list any skill perceived to be necessary for practice that wasn't covered well. Some new graduates working in specialty areas, such as obstetrics and oncology, perceived a lack of education in those areas. Five new graduates mentioned a lack of preparation for leadership; for example, they lacked skills needed for prioritization, teamwork, and organization, or dealing with incivility in the workplace. Three mentioned a lack of communication skills in certain areas, such as dealing with physicians and patients with special needs.

The largest proportion of responses (31%) related to a perceived lack of opportunity to practice clinical skills. Nurses perceived that the clinical skills needed had been introduced, but they'd had insufficient clinical time to practice those skills and gain confidence. One person referred to the importance of opportunities involving real patients rather than simulation. Twelve respondents said they hadn't had adequate opportunities to practice skills needed for I.V. therapy.

About 20% of the nurses in the sample perceived inadequacy in academic preparation related to critical care. Some specifically mentioned the lack of sufficient exposure to cardiac monitoring, mechanical ventilation, and other critical care technology.

Survey respondents were also asked to share impressions of any unnecessary emphasis in the nursing program. They made fewer comments in this area, but a few who are working in more general areas, such as medical-surgical units, viewed the specialty content of obstetrics and pediatrics to be superfluous.

Overall, physical assessment was most commonly considered to have been overemphasized. Ten percent of the nurses said that content emphasized in their physical assessment courses was never used in practice. Specifically, they mentioned techniques such as percussion and specialized techniques, such as using an ophthalmoscope and otoscope.

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This study found that the new graduates in the sample generally perceived their academic preparation to have been adequate for transitioning into professional practice. Consistent with the literature, the respondents wished they'd had more opportunities to practice clinical skills as nursing students. Although a common finding in the literature was that new nurses perceived their preparation in medication administration management to be deficient, that finding wasn't supported by this study.

This study found that some health assessment content often included in nursing programs may not be useful in typical entry-level practice. This finding is also consistent with the literature. Most respondents were employed in acute care medical centers where advanced assessment practices are less common.



A large percentage (41%) of the nurses sampled work in critical care areas, which might account for the perception that more academic preparation was needed in this area. In the past, most new nurses weren't placed in a critical care area initially; the nursing shortage in North Carolina has contributed to a reversal in that trend.

Limitations of this study include a small sample size restricted to one state and a relatively low survey return rate. Because the opinions of nonrespondents aren't known, they could vary significantly from the sample, making study conclusions misleading. Repeating the study with a larger, more geographically diverse sample is recommended. The ethnicity of study participants wasn't elicited on the survey, and this could be added in a future study.

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Because of the diversity of nursing practice, providing relevant preparation for the entry-level practitioner is always a challenge. Nursing programs should continuously be examined for practice relevance due to the dynamic nature of this field and ongoing changes in healthcare delivery and technology.

Overall, nurses in this study perceived that their academic programs prepared them adequately for professional practice. A large percentage of the sample (31%) perceived they'd had inadequate clinical practice time, making it possible that new nurses might not feel completely competent with practice-related skills when beginning their professional careers. Employers should take this into consideration when structuring orientation programs.

The planners for curricula in BSN programs might creatively and strategically consider ways to expand and improve the clinical practice opportunities for nursing students. For example, some allied health programs such as occupational therapy use a preceptor clinical model for the duration of the students' academic experience. These reality-based experiences provide mentoring structures, which are favorably rated in the literature by students with respect to preparation for professional practice. Nursing schools that use primarily a preceptor clinical model structure the clinical experiences throughout the nursing programs by pairing students with nurse preceptors instead of within clinical groups managed by an instructor from the nursing program. In the precepted model, the instructor still assumes responsibility for evaluating student performance with input from the preceptor but isn't present with the student in the clinical area except for intermittent checks.22



The Competency Outcomes and Performance Assessment Model (COPA) is an innovative curriculum framework based on core competencies and effective practice outcomes.23,24 Further research is indicated to empirically test these types of educational strategies and the relationship to successful transition into practice.

Practicing nurses should consider that new graduates may not feel completely competent with needed nursing skills. An individually tailored orientation program that matches new nurses with a qualified mentor may help them make a smoother transition into practice.

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