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Nurturing Future Nursing Leaders: Strategies for Improved Transition and Retention of New Graduate Nurses Cherry Pie de Veyra RN, BSNc NURS 558 San Francisco State University Dr. Mercy Popoola December 6, 2012

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This paper explores the recurrent problems of nursing shortage and retention. The crucial period of transitioning into the new role as professional nurse is described in terms of the conceptual model involving anticipatory socialization, organizational socialization and socialization outcomes. Growth and development of the new graduate nurse in terms of Patricia Benners From Novice to Expert is also explained. Research has shown that new nurses who quit within a year of employment were more likely to have experienced difficulties in role transitioning, as a consequence of inadequate orientation period or ineffective training program. The solutions proposed to address the negative factors identified include a nursing residency program lasting more than a year and a collegial clinical model for orientation used in nursing schools. Nursing leaders also play an important role in the smooth transition by maintaining a positive work environment that is conducive for growth and learning, as well as encourages mentoring future novice nurses. Keywords: new graduate nurse, staffing shortage, retention, role transitioning, nursing residency, nursing praxis, novice, expert and Patricia Benner

! $#"5#"%$&!$(6!$#"7(7! Nurturing Future Nursing Leaders:

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Strategies for Improved Transition and Retention of New Graduate Nurses For a new graduate nurse, the first two years of employment is a crucial period that will greatly determine whether they will successfully transition from being a novice to a competent staff nurse. This period of high stress and adjustment may also determine whether one will remain or leave the nursing profession altogether. Most new graduate nurses experience reality shock when they realize that the nursing profession is not what they had hoped it would be. With the nursing shortage and retention issues, nurses often have to work with inadequate staffing, increased workloads and more mandatory overtime hours. Compared to experienced nurses, new graduate nurses have the poorest retention rates (Hillman & Foster, 2011). The high demands of the job are particularly stressful for the inexperienced nurses, especially if they did not have an adequate orientation and training period. According to current research findings, approximately 30 percent of new graduate nurses and as much as 50 percent, in some instances, will quit within the first year of being hired (Hillman & Foster, 2011). With the economic downturn, most U.S. hospitals are trying to save money by eliminating or cutting down the new graduate training programs for nurses. Although training programs cost money, providing a good transition program to new nurses will be more cost-effective for the health care institution in the long run. Not only is high staff turnover very expensive, costing anywhere from $22,000 to over $64,000 per nurse, it also disrupts the work teams leading to decreased productivity (Finkelman, 2012, p. 285). Having less competent and experienced nurses may also compromise patient care and safety. If the problem with retention is not addressed and staffing shortage persists, other nurses will feel burnt out from the increased workload, excessive overtime and unending cycle of training new employees, most of whom do not stay longer than a year anyway.

! $#"5#"%$&!$(6!$#"7(7! Development of Nursing Praxis

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Nursing is a multifaceted profession and discipline that has evolved over the years. Nurses are no longer seen as mere caregivers; rather, we are now considered as professionals. Nursing is also considered as both an art and a science; hence, nursing practice must incorporate the most current and evidenced-based practice and standards with a caring approach to patient care (Potter & Perry, 2009, p. 9). Nursing school provides us with a broad knowledge base to prepare us for work in a variety of settings (Hillman & Foster, 2011). The different nursing theories and models serve as the basis and rationale for all our interventions and decisions. In nursing, it is not sufficient to simply memorize all the procedural steps, laboratory values, and diagnoses. There has to be an understanding as to why certain things happen or why a particular intervention is more appropriate than the other. Therefore, there is a strong emphasis on using critical thinking skills. We are encouraged to not simply accept things as they are, rather to question almost everything. Why is my patient experiencing the following signs and symptoms? What is the underlying cause? In nursing, things are not always straightforward. Patients may present themselves with a myriad of symptoms and comorbidities. Sometimes we can predict the outcomes because we have seen almost the same condition numerous times. That gut feeling or intuition that some nurses have is also gained through experience. One nurse, Catherine Green, wrote a paper arguing that intuition, specifically nursing intuition, is a valid form of knowledge (Green, 2012). She stated that nursing intuition is composed of the following four distinct aspects: (a) embodied knowledge; (b) well-trained sensory perceptions attentive to subtle details of complex, often rapidly changing situations; (c) a significant store of pertinent conceptual knowledge; and (d) a history of habitual actions intentionally directed towards achieving the best outcomes for our patients (Green, 2012). To be an effective and safe nurse, one must have both conceptual knowledge and clinical experience. The research strongly

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suggests that young nurses must have significant direct patient contact, which will enable them to immediately recognize patient situations that may make a difference between a positive and a negative outcome, particularly concerning life or death situations (Green, 2012). Transition Period: The First Two Years Working at a hospital for the first time with your own patient load can be quite terrifying. Without proper training and guidance from an experienced nurse or preceptor, the first year of employment becomes a time of great stress and uncertainty. There are data that prove new nurses experience increasing difficulties in transitioning from novice to competent staff nurse in acute care hospitals (Hillman & Foster, 2011). Having a mentor to provide feedback is crucial in gaining confidence and competence in the clinical setting. The Transition Process Some organizational theorists have designated the transition process from student to competent nurse as conceptual model with three phases: pre-work experience, actual work experience and work adjustment (Scott, Engelke, & Swanson, 2008). The various factors that contribute to the success or failure to transition into the new role are separated into three phases. Anticipatory Socialization. This period is characterized by everything that happens before work. We look at the highest education attained, Associate Degree in Nursing (ADN) versus Bachelor of Science in Nursing (BSN), as well as various experiences in relation to age, race, sex, marital status and personality; all of which may determine the expectations nursing students may have about life after graduation (Scott et al., 2008). They are more likely to experience reality shock if they have unrealistic expectations about working as a new nurse. Organizational socialization. This phase includes everything that happens when work begins, including the orientation process. Although almost all health care institutions still have an orientation program for new graduate nurses, these programs vary in length, intensity and

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content depending on the setting (Scott et al., 2008). For instance, some institutions offer a formal new graduate transition or residency program that may last for more than six months, while others may only offer a short and informal orientation program lasting no more than six weeks. The amount of time and depth of training greatly impacts the new graduates perception of work stress and satisfaction with the new work role. Organizational variables also include the working conditions and environment, such as stress level related to work demands, relationship with supervisor, physicians and other staff (Scott et al., 2008). Socialization outcomes. This last phase is the consequence of the previous two phases that is what happens after the adjustment period. A positive work experience and effective organizational orientation or transition period help foster work satisfaction and retention (Scott et al., 2008). On the other hand, conflict in the work environment, an inadequate organizational transition period and unrealistic expectations of the nursing role contribute to dissatisfaction and higher turnover rates among new graduate nurses (Scott et al., 2008). In 2006, Dr. Elaine Scott and colleagues conducted a study to examine the effect of anticipatory and organizational factors on job satisfaction and turnover from data collected by the North Carolina Center for Nursing (Scott et al., 2008). They found that almost 59 percent of 329 new graduate nurse participants reported that their needs were not met during the orientation period and the turnover rate for this group was as high as 60 percent out of 194 participants (Scott et al., 2008). Patricia Benners From Novice to Expert According to Dr. Patricia Benner (1984), a nurse goes through five levels of proficiency as he or she develops clinical expertise (Potter & Perry, 2009, p. 9). Over time, nurses advance from being the novice nurse who focuses on the technical aspects of nursing to the expert nurse who has developed nursing intuition through years of experience built upon a strong educational foundation (Dracup & Bryan-Brown, 2004).

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Novice. A novice nurse is either a nursing student or any nurse transitioning to a new specialty without prior experience (Potter & Perry, 2009, p. 9). For instance, an experienced critical care nurse transitioning to a hemodialysis unit is considered a novice in that situation. Learning is through following a precise set of rules and procedures (Potter & Perry, 2009, p. 9). Advanced beginner. This level refers to nurse who has some level of experience with the situation, including mere observations, but is able to recognize the principles behind the nursing care (Potter & Perry, 2009, p. 9). Competent. A nurse is considered competent when he or she has been in the same clinical setting for two to three years (Potter & Perry, 2009, p. 9). After this time, the nurse has a deeper understanding that allows anticipation of nursing care and planning long-term goals for the specific patient population (e.g., pediatric oncology patients) (Potter & Perry, 2009, p. 9). Proficient. A nurse is considered proficient after working for more than two to three years in the same clinical setting (Potter & Perry, 2009, p. 9). Proficient nurses are able to assess and understand situations holistically, as well as make decisions based on knowledge from previous experiences (Potter & Perry, 2009, p. 9). Expert. A nurse becomes highly proficient over time with more exposure to a variety of clinical situations, making them an expert in that field (Potter & Perry, 2009, p. 9). This nurse has the intuitive understanding of clinical situations and is able to anticipate potential clinical problems (Potter & Perry, 2009, p. 9). At this level, the nurse can be a mentor to other nurses. Factors Affecting Role Transition In 1999, a study was conducted to identify the various challenges experienced by 270 graduate nurses working in six acute care hospitals in the metropolitan area of Denver, Colorado (Casey, Fink, Krugman, & Propst, 2004). Data were collected through a survey from the participants at the following specific intervals: at baseline, three months, six months, 12 months,

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and additional follow-ups for groups employed longer than a year (Casey et al., 2004). The last part of the survey consisted of open-ended questions, including one question that asked participants to identify any difficulties they experienced during their role transition from student to staff nurse (Casey et al., 2004). Survey results included the following recurring factors that made role transition challenging for the graduate nurses. Lack of Confidence Graduate nurses reported increased anxiety and uncertainty about a lot of things. They were insecure and doubted if they had it in them to make critically sound decisions regarding patient care (Casey et al., 2004). They felt incompetent because they had trouble with time management and setting priorities (Casey et al., 2004). It was not until towards a year after employment that graduate nurses reported feeling confident and comfortable in their new role as a nurse (Casey et al., 2004). During the first six months, the new nurses were intimidated to communicate with physicians due to lack of experience and confidence (Casey et al., 2004). Tension Among Peers and Preceptors Several graduate nurses reported some tension between the new and experienced nurses. They did not feel welcomed and respected by the veteran nurses (Casey et al., 2004). They felt that their preceptors had forgotten how it felt like being the inexperienced nurse (Casey et al., 2004). More often than not, inadequacies on the part of the preceptors were not reported for fear of retribution and more hostile working relationships with other nurses (Casey et al., 2004). Struggle with Dependence and Independence A majority of graduate nurses struggled with the lack of a guiding figure or mentor. In some cases, there were no consistent preceptors during the orientation period (Casey et al., 2004). Others expressed feeling overwhelmed with responsibilities, yet they were uncomfortable delegating work to the ancillary or unlicensed personnel (Casey et al., 2004). Some of the

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participants reported feeling babied during the orientation period, which hindered their ability to acquire the necessary skills that would foster independence as a nurse (Casey et al., 2004). Stressful Work Environment Many of the participants reported feeling overwhelmed and stressed with the nurse-topatient-ratio, as a result of having inadequate nursing staff (Casey et al., 2004). Some struggled when they had to rotate from day to night shift in order to cover the staffing shortage (Casey et al., 2004). Because of the rapid turnover and problems with staff retention, a few of the graduate nurses had to assume the role of charge nurse or preceptor after only nine months of experience (Casey et al., 2004). They were subjected to more stress having to step up to the challenge when they themselves have barely adjusted to their new role as a professional nurse. Strategies for Improving the Transition In 2003, as an attempt to address the problem of nursing shortage, the Joint Commission (then known as Joint Commission on Accreditation of Healthcare Organizations or JCAHO) released recommendations for improving employee retention, which included providing financial support for internships lasting at least one year for new graduate nurses (Casey et al., 2004). The skill level of new nurses depends on where they went to school because the amount of clinical exposure varies from one nursing program to another (Hillman & Foster, 2011). For the benefit of the patients and the health care institutions, new graduates should no longer be expected to transition into the role of a professional nurse without a nurse residency or internship program. Evidenced-Based Residency Program In 2004, the management of the Magnet-designated Childrens Hospital of Michigan located in Detroit acknowledged that, although they had no problem recruiting new graduate nurses, they struggled with retaining them for longer than a year (Hillman & Foster, 2011). They were losing money so they decided to it was time to change their existing orientation program

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and develop a comprehensive and evidenced-based residency program starting in March 2005 (Hillman & Foster, 2011). From the five days orientation program, they started with 22 weeks allotted for the residency program, which was later reduced to 16 weeks in 2008 (Hillman & Foster, 2011). Instead of just having orientation speakers, they procured content experts, such as advanced practice nurses and respiratory therapists, to impart knowledge about specific conditions and diseases related to the pediatric patient population (Hillman & Foster, 2011). When there is a limited pool of qualified staff to serve as preceptor, the same nurses are asked to precept, which may lead to burn out especially if they have to deal with their own patient workload because of the staffing shortage (Salera-Vieira, 2009). To make sure they had an adequate pool of skilled preceptors, they conducted mandatory preceptor workshops for both novice and advanced preceptors (Hillman & Foster, 2011). A formal training is needed to educate the preceptors of their significant role and how they can better facilitate a smooth transition or adjustment into the workplace for the new graduate nurses (Casey et al., 2004). Preceptors were also recognized for their contribution and commitment in an annual recognition program organized by the house-wide preceptor subcommittee (Hillman & Foster, 2011). This new residency program greatly improved the retention rates of new nurses. Before the program, the one-year retention of all newly hired nurses was between 50 and 70 percent, while the twoyear retention rate was between 40 and 63 percent (Hillman & Foster, 2011). After the residency program, the one-year retention rate was as high as 100 percent with 182 of the 251 new nursing graduates who completed the residency program from June 2005 to October 2009 still employed to this date (Hillman & Foster, 2011). Collegial Clinical Model for Orientation The collegial clinical model (CCM) is the same orientation strategy implemented by most nursing schools wherein there is one clinical instructor for several students in a clinical setting

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(Salera-Vieira, 2009). This model was designed and utilized at the Women and Infants Hospital in Providence, Rhode Island to help the new nurses feel more comfortable because this was a familiar format for them, while allowing the hospital to save money (Salera-Vieira, 2009). The adult learning theory appropriate for the CCM is Lev Vygotskys sociocultural development theory, which introduces the concept known as the zone of proximal development (ZPD) (SaleraVieira, 2009). Vygotsky, a Russian psychologist, proposes that learning is facilitated in ZPD as the learner progresses from other-assisted or assisted performance to self-assisted (Salera-Vieira, 2009). In the first stage of assisted performance, learning occurs with the support and assistance from a more experienced peer or the instructor (Salera-Vieira, 2009). As the novice nurse progresses through the first to the second stage of ZPD, the instructors support decreases and eventually ceases while the learner assumes more responsibility; thus, learning becomes selfdirected (Salera-Vieira, 2009). By the third stage of ZPD, assistance is no longer needed as learning has been internalized, but this is not expected until the end of the orientation period (Salera-Vieira, 2009). The ZPD becomes more effective when scaffolding occurs, that is the instructor considers each individual learners needs rather than addressing the students as a whole (Salera-Vieira, 2009). Different individuals learn at a different pace and respond to different teaching styles. This model of learning will help with the struggle of having little or too much supervision as expressed by new graduates in the aforementioned study by Casey et al. When the instructor is able to vary the degree of support or guidance based on individual needs, learning becomes more effective. Conclusion Several studies and statistics have shown that new graduate nurses have the poorest retention rates. High staff turnover is financially debilitating for the health care institution because they can lose as much as $145, 000 (Hillman & Foster, 2011). That estimate was from

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2002 and the loss could be greater now if you factor in inflation. Job satisfaction and retention are greatly influenced by the quality of orientation received by the new graduate nurses. Nursing leaders can help address the issue of nursing shortage and staff retention by advocating for transition or residency programs that will foster competency, confidence and satisfaction among new nurses. Transition programs provide nurses with the tools to make the stressful first year into an opportunity for growth and development. New graduate nurses should not be used as an instant solution for the current shortage. Subjecting them to work in understaffed units without the proper orientation or training only adds to the stress, which then triggers high turnover rates. Nursing leaders also play an important role in maintaining a healthy work environment by enforcing zero tolerance for lateral violence or bullying among nurses. The experienced nurses should nurture and serve as mentor to the future nurses and leaders. What will happen to the nursing workforce, when the veteran nurses retire and we do not have competent and skilled nurses to take over? We start to develop our own nursing praxis in school as we integrate the various nursing theories and models learned in the didactic part of the program to our clinical practice. Our learning continues as we gain more experience and residency programs can help facilitate the smooth transition into the role of a professional nurse. My personal nursing praxis tree includes the following concepts: Evidenced-Based Practice, critical thinking skills, integrity/reliability, accountability, commitment, and human relations skills. The proper training and effective orientation will help ensure that care provided to all patients will always be based critically-sound clinical decisions and based on the most current evidenced-based standards of practice. Having adequate support from peers and preceptors during the transition period promotes a positive outlook on mentorship. It motivates the new professional nurse, possibly a future nursing leader, to also provide an equally positive experience to future novice nurses.

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Casey, K., Fink, R., Krugman, M., & Propst, J. (2004). The graduate nurse experience. Journal of Nursing Administration, 34(6), 303-311. Finkelman, A. W. (2012). Leadership and management for nurses: core competencies for quality care (2nd ed.). Boston: Pearson. Green, C. (2012). Nursing intuition: a valid form of knowledge. Nursing Philosophy, 13(2), 98111. http://0-onlinelibrary.wiley.com.opac.sfsu.edu/doi/10.1111/j.1466769X.2011.00507.x/full Hillman, L., & Foster, R. R. (2011). The impact of a nursing transitions programme on retention and cost savings. Journal of Nursing Management, 19, 50-56. Potter, P. A., & Perry, A. G. (2009). Fundamentals of nursing (7th ed.). St. Louis, Mo.: Mosby Elsevier. Salera-Vieira, J. (2009). The collegial clinical model for orientation of new graduate nurses: a strategy to improve the transition from student nurse to professional nurse. Journal for Nurses in Staff Development, 25(4), 174-181. doi: 10.1097/NND.0b013e3181b1d146 Scott, E. S., Engelke, M. K., & Swanson, M. (2008). New graduate nurse transitioning: Necessary or nice?. Applied Nursing Research, 21, 75-83. http://0dx.doi.org.opac.sfsu.edu/10.1016/j.apnr.2006.12.002