Nurse Education in Practice 15 (2015) 225e231

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Nurse Education in Practice

journal homepage: www.elsevier.com/nepr

‘What matters to graduates’: An evaluation of a structured clinical

support program for newly graduated nurses
Amanda Henderson*, Christine Ossenberg, Scott Tyler
Princess Alexandra Hospital, Woolloongabba, Queensland, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Effective guidance in practice is necessary for safe practice of clinicians upon entering the workforce. The
Accepted 17 January 2015 transition period is recognised as a time of significant stress as newly graduated nurses (novices)
endeavour to consolidate their nursing knowledge and gain mastery in a new working environment. This
Keywords: study explored novices perception of a structured clinical support program designed to assist their
Novice assimilation and development of good practice in the real world. Surveys and focus groups were con-
New graduate
ducted twelve months after novices commenced employment in a large tertiary hospital in South-East
Support
Queensland, Australia. Survey results from 78 novices (43% response rate), and feedback from a subse-
Preceptor
Program
quent focus group of the respondents, indicated that the program which provided interactive content
Retention days and supervised experience in an environment conducive to learning was successful in transitioning
novices. Novices placed considerable importance on largely intangible aspects of the interactive days,
such as emotional support and collegiality which contributed to their confidence. These intangible el-
ements of programs are often not measured and therefore their value not visible to those responsible for
continuous education. Of particular significance was that novices indicated their thoughts about practice
were given limited consideration. This is an important factor for future retention.
Crown Copyright © 2015 Published by Elsevier Ltd. All rights reserved.

Background benefits the hospital therefore has a keen interest in effectively

Over the past five years employment of graduates from Bachelor
of Nursing programs has reduced from 203 per annum in 2007 to
88 per annum in 2013 at the tertiary hospital presented in this
paper. While this stark decline can be attributed to external fiscal
restraints, namely, the government reducing the health budget
(Jewell, 2013), there has also been a steady trend to increase
retention of these recently registered novice nurses at the study
hospital. Newly registered novice nurses are a valuable component
of our continuing workforce. The cost of replacing a novice nurse in
Australia with a base salary of $48,000 is estimated to be $100,000
(Cubit and Ryan, 2011). The successful assimilation and engage-
ment of novice nurses directly impacts on patient safety, satisfac-
tion and staff retention. Lack of engagement can lead to poor
performance and high staff turnover. Given these recognised
* Corresponding author. Princess Alexandra Hospital, Ipswich Road, Woolloon-
gabba 4102, Australia.
E-mail address: Amanda.Henderson@health.qld.gov.au (A. Henderson).
integrating staff, in particular, novices.
The challenge is to effectively assimilate these newly graduated
nurses who are novices into high acuity nursing practice. Research
into the commencement of novices into the nursing profession
consistently identifies that they are particularly vulnerable to
feelings of uncertainty and isolation (Anderrson and Edberg, 2010;
Duddle and Boughton, 2007; Dyess and Sherman, 2009; Higgins
et al., 2010; Malouf and West, 2011). Johnstone et al. (2008)
emphasise that unless support is provided to address these chal-
lenges it is extremely difficult to make the transition successfully
from novice to advanced beginner-level practitioner and become
integrated into ‘the system’ as effective members of the team.
A focus on specific needs of the novice and appropriate guidance
in workplace norms and behaviours can assist toward socialisation.
Assistance in the socialisation process can make a significant
contribution to addressing feelings of isolation and poor perfor-
mance (Cubit and Ryan, 2011; Jewell, 2013). The evidence of the
value of support when provided to newly graduated novice nurses
is so strong that some countries have developed national stan-
dardized transition guidelines (Rush et al., 2013).

http://dx.doi.org/10.1016/j.nepr.2015.01.009
1471-5953/Crown Copyright © 2015 Published by Elsevier Ltd. All rights reserved.
226 A. Henderson et al. / Nurse Education in Practice 15 (2015) 225e231
Literature review
Internationally, the preparation of students of nursing to reach
the requisite standard to register as a nurse and enter the nursing
workforce is diverse. The diversity ranges from practice based
courses conducted in health facilities to education delivered pre-
dominantly in the higher education sector. While nurses have
participated in learning experiences in health facilities their fa-
miliarity with every day practices are likely to be highly variable.
Guidance and assistance in a civil context is essential for effective
integration (Kelly and Ahern, 2009). The literature suggests that
formal support should be available at least through the initial six to
nine month period and ideally up to one year, in particular, efforts
to integrate novices should be a focus for the first four weeks
(Johnstone et al., 2008; Morrow, 2009). Clinical units should be
healthy work environments that comprise supportive staff who can
accommodate novices expectations and expectations of others.
Staff support reduces the sense of isolation that newcomers can
feel. Students have reported that they appreciate the assistance
they receive as a student and when this is not forthcoming after
graduation they feel anxious and vulnerable (Kumaran and Curry,
2014). Education should focus on practical skill development and
preceptors who guide novices should receive a level of formal
training (Parker et al., 2013; Rush et al., 2013). There should be
opportunities for novices to connect with their peers (Rush et al.,
2013). Also, rotation through diverse clinical areas should be
limited to enable the novice to develop and consolidate their
knowledge and skills thus creating a sense of being a valued
member of the healthcare team (Newton and Kenna, 2007).
Structured programs that assist novices consolidate skills and
develop confidence in a safe environment increases work satis-
faction (Altier and Krsek, 2006).
Based on these research findings programs for these beginning-
level nurses should comprise:
 Available staff (Program co-ordinators, preceptors, educators,
team members) who can afford time, mostly in the first four
weeks, to provide guidance and feedback in the clinical area to
maximise the assimilation and contribution of the novice skills,
knowledge and ability to the work context (Goodwin-Esola
et al., 2009; Johnstone et al., 2008).
 Careful planning of the workload (breadth and intensity) by
team leaders so that increased responsibility and accountability
is scaffolded in accordance with the novices capabilities thereby
assisting in developing their confidence (Cubit and Ryan, 2011).
 Opportunities for novices to network with other novices to
assist with peer support and establishing relationships (Rush
et al., 2013).
 Effective preceptoring through a defined resource person who is
appropriately skilled and supported by the organisation to
conduct their role (Henderson et al., 2006; Jewell, 2013; Rush
et al., 2013).
 Provision of a structured and interactive education program that
engages nurses and can promote critical thinking and capability
(Anderson and Linden, 2009).
Workplace environments that readily assimilate novices
through facilitating their participation in a structured program and
engagement with their designated preceptor contribute to the
novice's successful integration. This also impacts on their learning
and ability to effectively practice (Goodwin-Esola et al., 2009).
Novices guided and integrated into the health care team apply
knowledge, skills and abilities to everyday practice situations
thereby maintaining quality care.
However despite the best intentions of these programs they
have not always successfully addressed the requirements of the
novice. One study reported that while most respondents had been
allocated mentors less than half were satisfied with their re-
lationships and approximately one-third responded that they were
dissatisfied (Parker et al., 2013). Reasons for the preceptorship not
working include: attitudes of preceptors; preceptorepreceptee not
being rostered together, inappropriate skill mix such that the pre-
ceptor is a team leader or managing other junior staff, inappro-
priate RN being allocated to precept or preceptor's
misunderstanding of the role they have been asked to fulfil (Cubit
and Ryan, 2011; Henderson and Eaton, 2013; Fox et al., 2005;
Johnstone et al., 2008).
These identified barriers to effective preceptorship and support
require that the clinical context develop organisational learning
qualities. Organisations or clinical contexts that encourage learning
have been described has having the following characteristics,
namely, assist in the integration and assimilation of staff, strive to
perform tasks to a high quality, reward and recognise staff, and
share and are open to new ideas (Henderson et al., 2010; Nembhard
and Edmonstone, 2006). Programs also need to consider the
development of these characteristics in their success.
Aim
The aim of this study was to determine the value of the program,
undertaken in accordance with the literature, to graduates assim-
ilation and engagement in the workplace. Of further interest was
whether the purposes and the activities within the program were
commensurate with developing recognised workplace character-
istics of learning in clinical practice to assure continued progression
for the novice. Information about successes and failures of initia-
tives to support graduates has been recognised as necessary to
build a potentially useful body of knowledge that educators
creating programs can draw upon (Jewell, 2013).
The Hospital Graduate Program
Clinical transition supervision and socialisation support is pro-
vided at the Hospital, centrally through the Nursing Practice
Development Unit by a ‘Graduate Program’, and locally, in each
clinical unit through assigning novices a preceptor. The program
designed to meet the needs of novices commences with an intense
system of support and tapers over 12 months. Initially novices are
provided four days of paid hospital orientation then two weeks of
supernumery time (time in which novices are not directly respon-
sible for patient care). Supernumery time is spent under the guid-
ance of a preceptor who works along side the novice with the same
rostered shifts for at least the first month of the novices' employ-
ment. Preceptors are skilled supervisors, identified by Nurse Unit
Managers, who are suited to support new staff. They typically
receive one day workshop training to assist them in this role. The
hospital provides study days (three days) in the first six months.
Study days mostly comprise interactive activities based on common
but significant clinical scenarios. During these learning sessions
novices work closely with each other and subsequently develop
valuable informal peer professional relationships. These develop
from the experiences of sharing challenges and debriefing in a ‘safe’
context. Arguably, novices' confidence and ability increases in
shared understanding in a non-threatening environment
(Goodwin-Esola et al., 2009). Sharing challenges and experiences in
a learning forum provides novices opportunity to develop rapport
with each other and debrief, and ideally novices develop confidence.
 A. Henderson et al. / Nurse Education in Practice 15 (2015) 225e231
The hospital additionally provides novices with assistance from
staff who are external to the clinical area. This includes a Program
Coordinator and Clinical Facilitator. These staff facilitate ‘Program
Study Days’ which are off-line days, that is, days that the novice
does not have a designated workload but can participate in learning
activities, that are targeted to address novices needs. The study
days routinely address clinical situations and provide opportunities
for socialisation during the first year of employment.
The success of these measures is largely dependant on how staff
in clinical areas assist novices to engage with the program on offer.
Each unit is instrumental in influencing the effectiveness of pre-
ceptorenovice interactions; for example, how many shifts they
work together, whether patient loads are co-located, whether
designated time is provided for feedback. Each local unit has
different arrangements and processes to assist the engagement of
the novice into the team. The exact nature of support required is
variable and therefore should be continuously reviewed (Edwards
et al., 2011).
This study through a survey of the novices and a focus group
with a small sample of the survey respondents explored novices
perception of clinical practice support provided through the pro-
gram that assisted their integration to clinical practice in the
organisation. The intention was to examine the findings to clearly
articulate and develop recommendations for clinical units about
practices that best assist novices assimilate into clinical practice
environments.
Method
A mixed method design was used. A survey approach based on
valid tools measuring organisational learning (Henderson et al.,
2010a) and learning in the workplace (Henderson et al., 2010b)
identified the value of particular elements of the program. Focus
groups were then conducted to derive more specific information
about the components that are effective in facilitating the tran-
sitioning of novices. The study therefore comprised two parts: part
one, survey of novices at completion of the one year program; and
part two, a focus group discussion following survey analysis to
provide insights into survey data findings.
Part one: Participants in part one were all staff employed at the
hospital following completion of a Bachelor of Nursing program
who participated in the hospital based program during 2011.
Part two: Participants in part two were a convenience sample of
novices from those who completed the survey.
Instrument
A survey tool was used for Part One. There were two compo-
nents of the tool:
1. Demographic data (including age, gender, clinical unit and
division);
2. Clinical learning organisational culture survey (CLOCS).
The questions were a compilation of items from existing vali-
dated tools; the Clinical Learning Organisational Culture Survey
(CLOCS) which measures the strength of attributes recognised as
important for quality learning environments (Henderson et al.,
2010a), and further items pertaining to engagement drawn from a
student clinical learning culture survey (Henderson et al., 2010b).
The following five subscales from the CLOCS were measured:
recognition, the reward/feedback systems operating within the
organisation, affiliation, interactions within the organisation,
accomplishment, performance standards, influence, the affect staff
have in unit operation, and dissatisfaction, whether staff are
227
dissatisfied within their workplace. Except for influence all sub-
scales have cronbach alpha >0.7 (Henderson et al., 2010a); there-
fore more statements pertaining to influence were added. Staff
responded using a likert scale range one to five with (1) strongly
disagree to (5) strongly agree. The items for engagement drawn
from the student clinical learning culture survey have cronbach
alpha of 0.87 (Henderson et al., 2010b). The items for engagement
from the student clinical learning culture survey (SCLCS) were
included as it was believed that this factor could be important for
graduates. The other items on the SCLCS pertain specifically to
‘learning’. As the focus for this study was ‘support’ as opposed to
‘learning’ the other sub-scales were not used. Cronbach alpha was
calculated for all the subscales. This was because only a sub-set of
the engagement questions were used, as fewer questions have been
shown to be just as informative and reliable, and also questions
were added to improve our understanding of influence. Cronbach
alpha's were satisfactory for modified scales. [Details are reported
in the findings].
Ethical approval
Ethical clearance for the research was obtained from the Hos-
pital Ethics Committee. All survey responses were anonymous as
there was no questions asked that could differentiate staff. While
the focus groups were taped the recording was securely stored and
only accessible to the researchers.
Data collection
Surveys were distributed to all novices employed in the orga-
nisation in 2011. Novices worked across all acute medical/surgical
areas. The total number across these areas was 180. Over 95% of
newly graduated nurses had been retained beyond their first year of
employment. This resulted in a large sample size. Surveys were
distributed to all novices in individually addressed sealed enve-
lopes via the organisation's internal mail system at the completion
of their program. Additionally, information about the survey was
sent via an email.
The focus group discussion was scheduled on a shift when a
majority of the novices were rostered. Attendance at the focus
group was sought through face to face communication with the
research team and the Nurse Unit Managers (NUM), Nurse Educa-
tors (NE) and Clinical Facilitators (CF), flyers and reminder stickers
in the staff ‘allocation’ book. The focus group was conducted in a
quite private area. It was informal in nature. The focus group eli-
cited feedback from the attendees about the contribution of the
program. Open-ended questions were asked during the focus
groups. Specific feedback from the participants was not solicited.
The participants were asked in broad terms about what they valued
in the program. The focus group discussion commenced with the
open-ended statement ‘How was the first year experience for you?’,
further questions included ‘what were the most positive/helpful
aspects?’ and ‘what could have been improved?’.
Data analysis
Survey data was analysed using statistical software analysis
package (STATA 11). The means for each of the subscales were
calculated. For each of the subscales the percentage of aggregated
responses for ‘agreed’, ‘neutral’ and ‘disagreed’ were determined.
Focus groups were recorded. The three researchers listened to the
tapes. The three researchers independently noted patterns, taking
into consideration the plausibility of the participant statements and
comments (Miles et al., 2014). The researchers came together, after
they had independently noted patterns, to discuss the patterns and
228 A. Henderson et al. / Nurse Education in Practice 15 (2015) 225e231
explore possible emerging themes. This data was subsequently
analysed through exploring the meaning of the responses that were
grouped.
Findings
Survey findings
A total of 180 surveys were distributed. Five surveys were
returned unopened to the research team which made the final
population of novices surveyed 175. Consent to participate was
implied by the return of completed survey. Seventy-eight surveys
were returned (43.3%). Sixty-three percent (49) of participants
were between 18 and 25 years of age. Males represented 15% (12) of
the sample population.
Cronbach alpha was conducted on all the sub-scales. Results for
those sub-scales that were not altered were consistent with the
existing literature, namely, recognition 0.92, affiliation 0.85,
accomplishment 0.85, influence 0.44, and dissatisfaction 0.74. As
previously acknowledged the cronbach alpha for the sub-scale of
influence was poor (Henderson et al., 2010a). The new influence
items that asked questions such as ‘I am encouraged to question my
existing practice’, and ‘staff are willing to discuss different ap-
proaches’ had an improved cronbach alpha of 0.76. The engage-
ment sub-scale that was a subset of the scale in the SCLCS had a
cronbach alph of 0.82.
The results indicate that on average the experience of novices
was positive. Important components of workplaces such as sense of
belonging (affiliation), sense of accomplishment (accomplishment),
sense of worth (recognition), and sense of engagement (active
participation) rated highly 3.9 to 4.2 indicating that participants
Graph 1. Means scores of sub-scales from survey responses.
‘agreed’ that these elements were present in the workplace (refer
Graph 1).
Of interest were the new items exploring whether novices felt
that they could make an impact on changing practice. These items
rated lower than 3.6; even lower still was how graduates rated their
dissatisfaction. This score was reversed as the items were worded
negatively. The score 3.3 suggests that respondents neither agree
nor disagree that they are dissatisfied (refer Graph 1). The aggre-
gated data shows that the respondents were most decisive about
the degree that accomplishment was important in their units and
that they felt included in the team (refer Graph 2). Mostly, gradu-
ates also felt that their work was recognised (refer Graph 2).
Focus group findings
Ten participants attended the focus group. Informed consent
was obtained prior to the commencement of the focus group. There
were three aspects of the program that emerged from the analysis
of the focus group discussion. These were: first, the importance of
the study days, in particular the network opportunities afforded
during the sessions; second, the positive working relationships
with their preceptors; and third, the positive contribution of the
nursing team where they worked. These three areas of discussion
dominated the focus group conversation. They were all discussed at
length with respect to their importance for transition to practice.
The value of the study days
The novices talked about the value of the study days that were
informative about specific practices at the hospital. The study days
were conducted shortly after the novices started which they also
found very useful. They provided a safe and pressure free
 A. Henderson et al. / Nurse Education in Practice 15 (2015) 225e231
Graph 2. Graduates reporting of agree, disagree and neutral for each subscale.
environment where they could ask questions and clarify their un-
derstanding. Most participants had attended all three study days. A
critical aspect of these days was that while knowledge was not new
to the novice it assisted them make sense of how it was now
important in their everyday practice.
For example one participant explained:
… three study, grad study days very informative and supporting
… helped with my grad year … although a lot of aspects covered
… was enough for me to take back to my ward if something
came up … I wasn't looking at my patient and thinking ‘where
do I start’ … it was hard to recall on my knowledge from uni …
by having the study days it refreshed my knowledge
Additionally the study days provided the participants the op-
portunity to collectively share experiences and obtain improved
professional comfort with performance progression.
The value of the preceptors
All participants identified that preceptors were very important
to their entry into the clinical area. They identified that preceptors
were instrumental in making them feel comfortable, so that they
did not feel uneasy.
“… I think that with your preceptor you build a bond with them
so you can always go to them and don't feel stupid because they
realise, especially in your first few weeks … that you're only new
229
… you may not have that relationship with other people, so it's
easier to go to that person (the preceptor)”
“… I go to mine (my preceptor) with everything”
Preceptors were also central to assisting novices engage with
the nursing team. Over time the novices bonded with the nursing
team, subsequent to working with the preceptor. At this stage the
team became very important for their continued development.
The exact nature of the noviceepreceptor relationship differed
for the new starters. In some cases the noviceepreceptor rela-
tionship commenced when the novice was a student and then
transitioned when the student graduated and became employed. In
these situations the novices reported a strong bond and lasting
friendship and mentor relationship. Other nurses described their
relationship as very purposeful, that is, the relationship was cen-
tred on orientation to specific practices rather then the develop-
ment of a rapport. With continuous time on the ward the preceptor
assumed much the same role as any of the nursing team. A number
of the novices identified situations where their preceptor had left.
They were not always replaced with another preceptor, however
often the novice had sufficiently assimilated that they were able to
approach a number of the nursing staff to assist them.
The value of the nursing team
All the novice nurses talked about how helpful the team was in
which they worked. They also talked about how important this was,
230 A. Henderson et al. / Nurse Education in Practice 15 (2015) 225e231
in particular, how it made their transition so much easier that they
could ‘ask anyone’ a question, rather than look for someone spe-
cifically, for example,
“we have a really supportive ward … if you didn't have that kind
of support, toward the end of the grad year you might be a bit
stuck … we have a huge range of people we can go to, so it's not
a problem, …”
“I know I can go to anyone in the ward and it won't be a
problem”
A few of the novices commented how the team demonstrated
their support by visiting them on a number of occasions to ‘check
on them’. The novices also recognised that no work environment is
perfect and that at times (although infrequent) a staff member may
not be helpful.
Greatest challenges
Novices identified that the greatest challenges were experi-
enced after hours when resource people are significantly limited.
Situations such as patient deaths (that can often occur after hours),
may not be experienced for some 6e8 months after commencing
employment. At this stage many staff have forgotten that the novice
may have not experienced a situation such as a death. It is situa-
tions such as these that the novices found confronting. Informal
support mechanisms were vital alongside the formal recognised
programs to assist with the significant challenges. Novices appre-
ciated the informal gatherings for new starters. The informal
network of support assisted the novices to discuss issues in a non-
threatening environment. They also appreciated when two or more
novices commenced in a clinical area together because this also
provided a ready available situation to share new experiences.
Discussion
This exploration of novices' perception of the workplace pro-
vides insights into the effectiveness of the program provisions to
assist novices become skilled clinicians. The findings from survey
data and focus groups indicate that the program provisions largely
meet the needs of novices as described in the literature. In the first
instance, participants described the benefits of the study day as
assisting them to competently complete their work. This was
supported in the survey data that indicated that novices felt a
strong sense of accomplishment. Further issues raised by partici-
pants were the contribution of not merely the preceptor but the
nursing team. Graduates can be largely dependent on the broader
team in the absence of other assistance (Parker et al., 2013). They
described the preceptor and most members of the team helped
them to ‘fit in’ and negate possible feelings of isolation. The effec-
tiveness of the preceptors and the broader nursing team were
verified by the positive sense of affiliation reported on the survey.
Impressions of this group of novices have also provided insights
into the largely intangible aspects of study days, such as emotional
support and collegiality, that are often not noticed and therefore
the value not visible. Delivery of programs with interactive content
days, followed up in a supportive learning environment, therefore
appears successful in transitioning new graduates.
Specifics of where improvements can be made, that is ‘gaps
identified in the intended and delivered aspects of the program’
have also been provided. In particular, caution needs to be exercised
regarding complacency about the offerings of the program. The
program confirms that we are reasonably successful in imparting
the practices of the nursing profession to ensure novices are safely
accomplishing tasks and effectively integrated into work practices.
Care needs to be taken that we do not indoctrinate novices to
existing practice but rather listen to them. As novices rated aspects
such as ‘being listened to … ’ and ‘having a say … ’ as the lowest we
need to consider how we can better integrate their contribution to
practice. Nursing workplaces have been recognised for their strong
practice traditions which can limit their receptiveness to the
contribution of others (Henderson et al., 2012). This may eventually
impact on retention an important rationale for supporting these
novices.
Conclusion
The opportunities valued by novices included, in particular,
scaffolded learning assisted by the study days and the relationship
with the preceptor. This was effective in ensuring the novices could
perform their nursing work competently. Clinical learning was
effectively staged by preceptors so that novices were not over-
whelmed. This assisted in building their confidence. Preceptors and
the broader nursing team also assisted their assimilation so that
novices did not feel isolated and vulnerable. Furthermore, informal
support created through social networking made possible during
the study days was viewed as instrumental to their overall
emotional well-being.
Recommendations
1. Effective preceptoring is best achieved through relationship
building. Such relationship building fosters scaffolded learning
that accommodates individual needs with available learning
opportunities. The clinical area needs to enable this through
provision of adequate time for discussion and feedback.
2. Graduate workshops are most valuable not for ‘new’ knowledge
but rather making previous learnt knowledge accessible. Activ-
ities need to be relevant and targeted to assist the novice make
sense of their knowledge so that they are competent clinicians.
3. Informal support that creates a strong network is vital for
newcomers, yet, largely invisible and therefore is at greatest risk
when rationalising programs. Elements of the program need to
be conducted in a safe context without the immediate clinical
demands for novices to share and learn.
Conflict of interest
None to declare.
Acknowledgement
The team wishes to acknowledge the Private Practice Trust Fund
at Princess Alexandra Hospital for their support through a Private
Practice Fund grant.
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