Author’s Note
During my second semester of nursing school, I was assigned to a cardiac medical-surgical floor for clinical. Every Friday, myself and five other students arrived at the hospital up to an hour early to avoid the possibility of shuttle delays or rush hour traffic making us late. We would sit in the lobby, forcing down a few bites of food while balancing notebooks on our laps to maximize studying time, and, to put it simply, stress. Each week, our discussions were the same. “I can’t do this today.” “I’m terrified.” “I don’t know what I’m doing.” I expected to feel more competent and independent as the semester went on, but I rarely did. Sure, there were flashes of pride when I gave my first injection or successfully checked a blood sugar or completed a thorough assessment, but these moments were more often overshadowed by feeling small and out of place.
In contrast, the nurses I worked with–all of them–exuded a confidence and self-assuredness that I could only envy. Many of them hadn’t even been out of school that long, yet they seemed to enter every room knowing exactly what they were doing. They were personable towards patients and could answer any and all questions (a stark contrast from my robotic, “hi, I’m Lila and I’ll be your student nurse today” and meek, “I don’t know, let me ask your nurse.”) I couldn’t open the little medication packets (pills flew across the room as I tried to tear the packaging), struggled to get a simple blood pressure (even with the special automatic machines), and was no help when CNAs asked me to assist with a boost. I was getting straight A’s in all of my classes, but felt like a terrible nurse. Today, with just two semesters left before I graduate, the thought of having RN next to my name in less than a year frankly terrifies me. I think back to where I was 12 months ago before starting clinicals, and honestly, I don’t feel all that different. How will I be prepared to care for patients in a world where the population is getting older, sicker, and in need of more advanced nursing expertise than ever? More importantly, where and how did the nurses I worked with gain the confidence and competence they practiced with? When does that transition occur, and how can employers facilitate positive development in the new graduates they hire?
Last year, I completed a self-directed study on the role of the school nurse, a field I am very interested in pursuing. This job is, of course, a very independent one. Many times, school nurses are the only healthcare providers in the building and the person to turn to in the event of emergencies, sicknesses, or legos stuck in places they shouldn’t be (true story.) At one school where I shadowed, I asked the nurse if she thought the job was possible for new graduates. She was adamant in her response. “When you graduate you don’t know anything,” I was told. At first, I was indigent. Of course I could handle it. But now, a year into clinicals, I feel relieved and oddly comforted by her advice. Even in another year, I don’t have to have it all together. But I do need to get it together eventually. How will that happen?
From Student to Nurse: Preparing New Graduates for Success and Competency in Practice
The need for registered nurses in the United States is growing rapidly as the population ages and the Baby Boomer generation faces retirement and increased healthcare needs. In fact, the Bureau of Labor Statistics estimates that while over 177,000 new nurses will enter practice by 2032, a massive shortage will still exist, with nearly 64,000 RN positions left unfilled in 2030 (American Association of Colleges of Nursing [AACN], 2023). While the lack of nurses to meet the country’s healthcare needs is certainly an important issue, the expansion of the workforce is also critical. New nurses entering practice need proper mentorship, education, and training to effectively care for patients who are often sicker and presenting with more comorbid diagnoses than ever. With a 2023 article in the Journal of the American Medical Association finding that more than 25% of nurses in the United States planned to leave the field with concerns of burnout and continually increasing workloads (AACN, 2023), it is clear that appropriate measures must be taken to reduce excessive stress among new graduates and seasoned nurses alike.
The transition to practice for new nurses is a time often characterized by frustration and a lack of confidence in one’s ability to care for patients with competence. “Reality shock,” a phenomenon introduced by nurse and educator Marlene Kramer in 1974, describes the difficulty of learning one’s true unpreparedness when beginning a role they expected to feel ready for (Kramer, 1974). During the second phase of this theory, termed the “shock phase” by Kramer, nurses begin to recognize the disconnect between their expectations and actuality of their role, including the potential for increased responsibilities. This can be incredibly challenging. In fact, the National Council of State Boards of Nursing (NCSBN) reported in 2018 that roughly one in four nurses left their job before a year, while another study found that 90% of new nurses felt less than prepared to provide “safe, effective care” (Powers et al., 2019). Fortunately, strategies can be utilized to mitigate burnout, increase confidence, and decrease the risk of quitting a job or leaving the profession as a whole.
Success as a new graduate depends largely on one’s experience in nursing school. Indeed, a major contributing factor to reality shock is the disconnect between clinical and class content during schooling and the actual demands of acting as a registered nurse (Powers et al., 2019). Students in clinicals may be tasked with caring for one or two stable patients under the close direction of a nurse, yet in practice they often are assigned higher numbers of patients right away and tasked with many additional responsibilities such as answering questions of families, collaborating with other members of the healthcare team, and facing more complex care needs (Powers et al., 2019). Additionally, the topics and priorities heavily emphasized by most nursing schools, such as nursing theory and diagnoses, may not mirror the ones in practice, which included task management and practical skills (Baharum et al., 2023). Clinical experiences can also be hindered by large numbers of students and lack of opportunities to practice skills, among other factors (Powers et al., 2019). But how can nursing schools maximize learning and practical experiences for students? Studies suggest implementing “rigorous rules and policies” to enhance confidence and self-discipline (Baharum et al., 2023), providing ample opportunities to connect clinical experiences to classroom learning, and ensuring competency in clinical skills performances instead of relying on exam scores alone to determine depth of understanding (Kavanagh & Szweda, 2017). Ultimately, students should graduate with an understanding of how to carry out safe practice (Powers et al., 2019), as well as navigating the job search and hiring process (Hallaran et al., 2022). It is during the early weeks and months of working in the role that clinical judgment, care planning, and time management skills–the characteristics needed to thrive as a nurse–are truly developed.
It is clear that nurses first entering practice are not yet fully equipped to handle the demands of full patient loads and potentially unstable conditions. While there are many factors that aid in new graduate success, three major components-personality values, workplace environment and transition to practice programs-are particularly vital. The first of these, personality values, was studied as part of a scoping review conducted by Malaysian researchers in 2023. They identified a number of attitudes, behaviors, and thought patterns that contributed to new nurse readiness and adaptation (Baharum et al., 2023). These included proactivity, or the ability to obtain information and resources on one’s own. While challenges may still occur, learning to navigate them with curiosity and self-discipline can seek to improve confidence, and, ultimately, competence. Self-awareness is another attribute identified as important for new nurses. This trait allows nurses to better adjust to a new environment, connect with more experienced staff, and fit into and contribute to the work environment. Similarly, self-confidence, or a belief in one’s abilities, if necessary for development of problem-solving skills, working through conflicts, and navigating challenging patient situations (Baharum et al., 2023). While some may exhibit these traits more naturally, it is also possible to build them through appropriate education, mentorship, and work environment.
A supportive workplace environment was another factor identified as crucial for new graduate development. Studies have shown the importance of integrating new nurses into unit culture immediately upon their hire (Baharum et al., 2023). This includes introductions to all staff, engagement in meetings and activities, and thorough orientation to the unit, such as access to workspaces. Additionally, the general atmosphere of the unit should be supportive, welcoming, and free of judgment. The Malaysian scoping review by Baharum et al highlighted the correlation between a new nurse’s ability to ask questions of senior staff without criticism and their confidence and stress levels. Similarly, a Canadian study found that the most common struggles among new nurses included unsupportive work cultures, bullying, and unapproachable coworkers or mentors (Hallaran et al., 2022). Thus, more experienced nurses on the unit should be willing to answer questions and facilitate a positive environment while still providing feedback and introducing workplace norms for newcomers (2023).
Along with a positive unit culture comes the importance of an environment conducive to learning (Baharum et al., 2023). Nursing supervisors should assign new graduates patient loads and tasks that facilitate development while ensuring safety and attempting to reduce stress. While graduates eventually must learn to provide care in more complex situations, it is not recommended that they be assigned these cases immediately. Along with increasing their stress, it also puts the patient in danger. New nurses should be given tasks and assignments that teach them time management and promote safety. A survey conducted in China found that new graduates felt especially unprepared to care for dying patients, and these assignments caused elevated anxiety, depression, and lowered self-confidence (Baharum et al., 2023). Thus, while death is something nurses must learn to navigate with confidence and grace, assigning new graduates too many of these cases can be negative as a whole. In addition to opportunities to ask questions, workplaces should also promote continued professional growth, such as chances to gain certifications and in-service trainings (Hallaran et al., 2022)
The final factor related to culture and environment is just how much time–and what time–new nurses spend at their workplace. While some research has suggested that working more hours initially (such as over 49 hours in a 2-week period) can facilitate an easier transition and increased engagement, it is also clear that too many hours on the job can reduce performance, quality of life, and outlook on work (Baharum et al., 2023). Working greater than 10 hours a day was correlated with elevated fatigue and workplace injuries, and night shifts had similar effects such as lower job satisfaction and decreased sleep quality (Baharum et al., 2023). Longer or irregular hours also increased the nurse’s intention to leave his or her job. As a whole, it is clear that new nurses need regular and adequate exposure to their role, but overly excessive hours, including long shifts, can prove detrimental. Similarly, graduates scheduled for nights or irregular hours may need decreased workloads or reduced hours to account for the difficulty of their shift timing.
Arguably the most crucial factor in new graduate nurse success is transition to practice programs. Given the stress of reality shock associated with the transition to practice (TTP) period, programs designed to teach and mentor new nurses are essential to developing competency (Powers et al., 2019). Sometimes referred to as nurse residencies, these programs have been shown to reduce staff turnover and its associated costs, decrease falls, pressure ulcers, and other negative outcomes of poor care, and increase safe practices (Powers et al., 2019). A large-scale 2015 study conducted by the National Council of State Boards of Nursing (NCSBN) found that residencies have the most favorable outcomes when they are overseen by preceptors, are six months in duration at a minimum, and focus on the development of clinical reasoning (Powers et al., 2019).
The cornerstone of TTP programs is the preceptor, who serves to facilitate the new nurse’s first few months of employment and bridge the gap between knowledge acquired in school and putting skills into practice. Preceptors aid in the development of clinical reasoning, and should offer frequent feedback and opportunities for reflection (Powers et al., 2019). Yet perhaps one of the most important roles of the preceptor is to help new nurses gain confidence and decrease anxiety. Thus, it is imperative that the preceptor is not only an excellent nurse themself, but also a trained educator. They too require proper training and mentorship to develop teaching skills, especially on how to facilitate development of clinical reasoning (Powers et al., 2019). New nurses are not the only students who require teaching.
As a whole, it is clear that the success of new nurses depends on many people. The educators who help students develop a base for safe practice and clinical reasoning while in nursing school. The coworkers who provide a warm, welcoming environment and answer questions without judgment. The managers who assign tasks, patients, and workloads with care. The preceptors and mentors who are the cornerstone of a new nurse’s orientation to the field. And the nurses themself whose personality traits, beliefs, and attitudes carry them to develop competence. New graduates need plenty of support–which takes time, resources, and money–but the result is a stronger, most robust field that is prepared to take on the demands of the profession with confidence.
Concluding Thoughts
Upon writing and finishing this essay, there are two words that jump out to me immediately. Common sense. Isn’t it true, after all? Doesn’t it make perfect sense that new nurses need lots of support, mentorship, and resources to take on the profession of caring for the sick? Do we really need an expert to tell us that graduates thrive in welcoming environments and with appropriate patient loads? There is no secret sauce to becoming one of those confident, competent nurses I envied during clinical–just lots of practice, mentorship, and time. Yet the question still remains: Is it being done? If all of this is so obvious, why are new nurses still leaving the profession in droves, and is their retainment out of our control? While I did not research whether or not these measures decrease nurse turnover, I would imagine that the answer is just as obvious. It is worth looking at how often these practices are implemented–the TTP programs and appropriate task allocation and environments that encourage asking questions–and the retention at the workplaces that practice them versus those that don’t.
Perhaps I only wrote this piece to stop feeling so stupid. Like the school nurse who told me I would know nothing when I graduated, this research reassures me in a way. A year from now, I am not expected to have it all together. Putting it all together will take lots of time and support, and that’s completely normal. Yet the burden also falls on my shoulders to make sure I prioritize looking for places of employment that will support and nurture my development. The scary thing is, new and unprepared nurses may be thrown into patient loads they are unable to safely handle due to lack of staff or inadequate workplace training and orientation. In the end, with the lives of patients at risk, we can’t afford not to properly educate our newest nurses and keep them in a profession that so desperately needs them.
References
American Association of Colleges of Nursing. (2024, May). Fact Sheet: Nursing Shortage. Retrieved 9 June, 2024, from https://www.aacnnursing.org/Portals/0/PDFs/Fact-Sheets/Nursing-Shortage-Factsheet.pdf
Baharum, H., Ismail, A., McKenna, L., Mohamed, Z., Ibrahim, R., & Hassan, N.H. (2023). Success factors in adaptation of newly graduated nurses: a scoping review. BMC Nursing, 22(1), 125. https://doi.org/10.1186/s12912-023-01300-1
Hallaran, A.J., Edge, D.S., Almost, J., & Tregunno, D. (2023). New Nurses’ Perceptions on Transition to Practice: A Thematic Analysis. Canadian Journal of Nursing Research, 55(1), 126-136. https://doi.org/10.1177/08445621221074872
Kavanagh, J.M., & Szweda, C. (2017). A Crisis in Competency: The Strategic and Ethical Imperative to Accessing New Graduate Nurses’ Clinical Reasoning. Nursing Education Perspectives, 38(2), 57-62. | DOI: 10.1097/01.NEP.0000000000000112
Kramer M. (1974). Reality shock, why nurses leave nursing. C. V. Mosby.
Powers, K., Herron, E.K., & Pagel, J. (2019). Nurse Preceptor Role in New Graduate Nurses’ Transition to Practice. Dimensions of Critical Care Nursing 38(3):p 131-136. https://doi.org/10.1097/DCC.0000000000000354
