Transition into the role of the professional nurse is cause for great excitement and apprehension for the student nurse. As a soon to be BSN graduate, this author noted a similar theme amongst classmates which provided an opportunity for inquiry to highlight key strategies for successful transition for the entry-level professional nurse.
Patricia Benner’s (1982) model From Novice to Expert provides a theory of skill acquisition to examine the transition of a novice nurse who is primarily focused on task oriented professional nursing care to the highest level, the professional nurse expert, who is able to multitask, has proficiency in the clinical area, high level of intuition, and analytic ability and can apply these characteristics in new situations by recalling former experiences. There are five stages of the socialization model; novice, advanced beginner, competent, proficient, and expert (Benner, 1982). The new graduate RN enters at novice or advanced beginner depending on clinical exposure during entry level preparation. Using the Benner model as a framework to review transition the author has found common themes to discuss cultural work environment and expectations defined by the new graduate RN.
Hooper-Kyriakids (2005) utilizing the Benner Model as a framework emphasizes the uneven transition for new graduates. Hooper-Kyriakids (2005) main point for professional RNs is to support the transition by cueing novice and advanced beginners with their clinical decision-making. In addition, nurses should provide a comfortable space and a non-threatening environment to ask questions (Hooper-Kyriakids, 2005, speaker). Hooper-Kyriakids (2005) acknowledges the gap from nursing theory in academia to practice as the professional nurse at the bedside making the transition stressful and difficult (Hooper-Kyrakids, 2005).
It is well established that nursing retention continues to be a major issue for the nursing profession. Dracup (2007) projects from a survey in 2004 that 55% of respondents had intention to retire from nursing between the years, 2011 and 2020. Another startling fact leads to a 50% turnover rate of professional nurses within this time (Dracup, 2007, p.328). Authors Hardin-Pierce & Butler (2005) site 53% of new graduates changing their job within their first year of work (Hardin-Pierce & Butler, 2005). These high turnover rates combined with the lack of senior or expert nurses make it challenging to support the transition for the new graduate RN. In addition these figures represent an increased demand for nurses and more effective models to streamline new graduate RNs into a ‘competent’ and ‘proficient’ nurse on the patient care unit.
The 50% turnover rates presented by Dracup (2007) and Hardin-Pierce and Butler (2005) call attention to 53% of new graduate RNs who leave their job within a year, highlights the issue of ineffective transition. Hardin-Pierce & Butler (2005) describe new graduate RN’s who experience a lack of supportive culture and horizontal violence which correlate to these dismal figures (Hardin-Pierce & Butler, 2005). Lavoie-Tremblay, O’Brien-Pallas, Gelinas, Desforges (2008) estimate by 2020 the United States will have a projected shortage of 808,400 full-time nurses at 29% (Lavoie-Tremblay et al, 2008). Lavoie-Tremblay et al (2008) highlight the changes that need to be made within the organizational structure that will positively impact work environments for new graduates by making more incentives (Lavoie-Tremblay et al, 2008). New graduate RN’s need knowledge concerning issues that affect transition to be able to speak to them in upcoming interviews and job opportunities.
Defining Aspects of Transition
There are many different orientation to the workplace models for the new graduate RN including the mentoring model, preceptor, and residency program. Mills & Mullins (2008) studied the mentoring model implemented in California to increase retention rates (Mills & Mullins, 2008). Mentors were assigned to new graduate RNs for support and guidance. The mentor completed a 16-hour certification program, which defined their role and expectations (Mills & Mullins, 2008). The evidence concluded increased job satisfaction and professional confidence when relationships lasted over one year (Mills & Mullins, 2008).
Wieland, Altmiller, Door and Wolf (2007) define the preceptor as “helping neophytes transition to the role of professional nurse, preceptors serve as coaches, role models, socializers and evaluators” (Weiland et at, 2007, p. 316). Weiland et al (2007) attributed success to building confidence in many skills they acquired including: time management, decision-making, collaborating and advocating for their patients (Wieland et al, 2007). Paton & Binding (2009) discuss the clinical expertise and attributes of the preceptor to properly assess the readiness of the new graduate RN using “intentional process of thinking, reflecting, debating and questioning students’ behaviors in relation to their understanding and intentions within clinical situations” during a three month time period (Paton & Binding, 2009, p. 115). Paton & Binding (2009) emphasize the dynamic relationship and evaluation involved in the preceptor role and difficulty preceptors face when new graduate RNs are not ready to practice independently after three months (Panton & Binding, 2009).
Ricker (2008) describes the effectiveness of a new residency program lasting one year (Ricker, 2008). The first three to six months the new graduate RN works with a bachelor’s prepared RN focusing on clinical practice and skills. The second half of the year is geared toward building critical thinking skills by reviewing experiences of the new graduate RN with the input of the preceptor (Ricker, 2008). Throughout the program the new graduate RN communicates with the selected preceptor and clinical leaders to discuss success and challenges related to professional development (Ricker, 2008). The dynamic and open dialogue present within many steps of this program lend to a very appealing workplace for the new graduate where they are involved in their own progression through the transition, which has lead to a more loyal and committed nurse (Ricker, 2008).
The authors Miller & Mullins (2008), Paton & Binding (2009), and Ricker (2008) all discuss different approaches and outcomes for new graduate RNs, however there is not enough evidence based practice to endorse one model. The programs vary in length from 3 months to one year without evidence based practice or conclusive data of what is most successful. All programs initiate a didactic and clinical component before allowing the new graduate nurse to work independently (Ricker, 2008, Paton & Binding, 2009, Miller & Mullins, 2008).
Characteristics of Work Environment
Lavoie-Tremblay, Wright, Desforges, Gelinas, Marchionni, Devniok (2008) discuss the different demands of a new generation of nurses. The largest percentage of new graduate RNs are Generation Y born between 1980-2000 who expect different things from their work environment, which often leads to job dissatisfaction. Generation Y new graduate RNs responded to a recent survey of 3,009 participants which yielded 43.4% experiencing high psychological stress within the clinical setting. Nurses will comprise four generational groups and still have to make their way through the transition model as Patricia Benner developed in the nineteen eighties (Lavoie-Tremblay, 2008).
New graduate RNs should be aware of the qualities they value in their workplace as to find a better fit. Lavoie-Tremblay et al (2008) describes Generation Y, “as the ideal workforce. They combine the work ethic of baby boomers with the can-do attitude of veterans and the technological savvy of generation Xers. They value participation, collaboration and support as opposed to competition. These outspoken and confident employees expect constant feedback, frequent praise and consistent rewards” (Lavoie-Tremblay et al, 2008, p. 726).
The current research by Lavoie-Tremblay et al (2008) on transition links the correlation of effort and reward balance to maintain job satisfaction (Lavoie-Tremblay, 2008).
As a new graduate RN it is important to reflect on key components of organization culture because it can predict your commitment to the organization (Lavoie-Tremblay et al, 2008). The Benner model involves engagement between the novice nurse and the proficient and expert nurses to develop along the continuum of transition. Lavoie-Tremblay et al (2008) demonstrated that the greater the new graduate RNs receive social support and a welcoming work environment the less they report psychological stress and feel a greater competency with their skills (Lavoie-Tremblay et al, 2008).
Ricker (2008) emphasizes a supportive network in the transition experience of new graduates through the residency program at University of Colorado Hospital (Ricker, 2008). The model is being studied in an attempt to find evidence based practice for new graduate transition programs. The yearlong program evaluates the new graduate RN in collaboration with the preceptor and clinical leaders regarding their perceptions of preparedness for clinical practice. Additional experiences can be facilitated to ensure the readiness of the nurse to transition into independent practice (Ricker, 2008). The nurse residency model has included a debriefing and reflective element to the transition process to aid in both personal and organization learning about the new graduate RN transition (Ricker, 2008).
New Graduate RN Expectations
A study done by Heslop, McIntyre and Ives (2001) studied the expectation of the novice nurse about the transition process of the new graduate professional RN. There was direct link to an optimistic outlook for the new graduate RN’s if the novice nurse participated in a senior preceptor model (Heslop et al, 2001). The literature suggests a gap in knowledge related to the new graduate nurse expectations because of the latest emphasis made on direct patient care and outcomes research found in the landmark study in 2000 To Err is Human. This study publicized the number of people in harm through medication errors and hospital acquired infections which called attention to the outcomes of patient care. This study heightened a sense of immediacy and often fear for those beginning to practice.
John Blanton (2007) began nursing later in life writes about his concern, “But though my new career terrified me, tired me and was impoverishing me, it yielded that satisfying sense of purpose that had motivated me at the start. As early as those first few weeks, I could see that even my frantic novice’s efforts contributed to a cumulatively positive effect, despite my chronic fear of inflicting harm. In time the great majority of patients improved” (Blanton, 2007, p. 4).
Blanton (2007) emphasizes the psychosocial demands of nursing and reinforces Benner’s model of transition into professional practice (Blanton, 2007). With greater assessment skills and understanding of the complex patient care needs new graduate RNs move through the ladder of Benner’s stages with time and experience on the patient care unit.
Sewell (2008) describes the process of journaling as an avenue for new graduate RN’s to learn from their experiences (Sewell, 2008). It gives their clinical leaders and mentors a tangible topic to discuss how they handled certain situations and what they can learn from one another. Journaling has shown to improve critical thinking skills and engage experienced nurses with graduate nurses and cultivate professional growth for all new graduate RNs (Sewell, 2008). The reflection process can strengthen decision-making and coping strategies through practice (Sewell, 2008). In a sense the journaling process speaks directly to Benner’s From Novice to Expert model by giving the new nurse experiences to share with his or her peers and seasoned nurses.
As a new graduate RN embarking on your professional nursing career it is crucial to find an ethical work environment and culture committed to your professional developmental. The environment will have a structured orientation program that has ongoing communication regarding the challenges the entry-level nurse faces as a professional RN. Assessing personal and professional strengths guide the new graduate RN in selecting an environment where the RN can excel. Finding an environment that values your strengths leads to positive outcomes for the individual and institution. Positive outcomes will foster professional work decreasing the nursing shortage, increasing retention and leading the new generation of the nursing workforce.
Benner, P. (1982). From Novice to Expert. American Journal of Nursing. March, 402-407.
Blanton, John. Care and Chaos on the Night Nursing Shift: In a Search for purpose, an editor changes careers, ‘He’s asking for You Again.’ Wall Street Journal. New York: April 24, 2007.
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