Abstract
New graduate nurses face a host of challenges that impact successful transition to practice. Health care organizations thus need to understand how changes in the health care landscape impact new graduate nurses who are transitioning to the practice environment. This commentary discusses challenges and possible solutions to successful transition of new graduates into the work environment.
In an ever-changing health care environment, one thing that remains unchanged is the demand for nurses, and the need is more critical now than ever before. Clinical practices are under added pressure to operate in a lean, efficient manner due to shrinking reimbursements, increased regulatory oversight, and increased consumerism [1]. This pressure demands that education programs produce nurses who are work-ready from the moment they flip their tassels.
In 2014, the Health Resources and Services Administration reported that North Carolina will be among the states to experience the greatest shortfalls in registered nurses (RNs) by 2025, with a deficiency of nearly 13,000 [2]. The demand is expected to increase for a variety of reasons, including population growth, aging of the existing workforce, more patients with complex and chronic conditions, and the expansion of health insurance to the underinsured and uninsured [3].
Leaders across the country have implemented creative strategies to address the challenges employers face in successfully transitioning new nurses from academia to real-world practice. In this commentary, we will discuss several challenges and potential solutions to address those obstacles.
Challenges
New graduate nurses face many challenges when transitioning to the workforce. These include an increasing number of patients with complex conditions and multiple comorbidities, lack of access to experienced mentors and coaches, generational diversity in the workforce, performance anxiety, and bullying. To compound the problem, these issues often occur simultaneously.
It is no secret that nurses feel stress and fatigue during this transition. Nurses must manage patients, manage relationships with providers and families, and lead the interprofessional team. When not provided with supportive relationships, novice RNs who care for complex patients often feel overwhelmed and exhausted, and they may suffer from significant anxiety, all of which can lead to attrition [4-6].
Hospitals are seeing more patients with complex chronic conditions. In Eastern North Carolina, statistics show disproportionately high rates of heart disease, cancer, diabetes, end-stage renal disease, obesity, and mental health–related conditions; all of these conditions are attributed to lack of access to primary care, limited access to preventive care, limitations in funding for care, and deep-rooted cultural and socioeconomic issues [7, 8]. Uninsured and underinsured patients often do not seek care until their condition requires immediate evaluation, at which time their only resource is the acute care setting [9].
The hospital industry is seeing experienced nurses depart due to retirements, increased workloads, declining resources, lack of upward mobility, and increases in ambulatory opportunities. Thus organizations are often unable to leverage seasoned staff as mentors to direct new graduates. For millennials, coaches are essential to a successful transition [10]. Organizations must also account for generational diversity when establishing the mentoring relationship [11]. Compared to their predecessors, millennials expect more structure; if these needs are not met, organizations can anticipate turnover [12, 13].
Properly addressing fatigue is also vital, as role ambiguity is a significant contributor to burnout among nurses [14]. Studies have suggested that, when professionals self-identify as “burnt out,” they are more likely to be disconnected from their work and their colleagues, which causes them to work in more detached ways [14-18]. Stressed and detached nurses lead to poor work performance, which can be tied to serious patient safety events.
Workplace bullying has been described as a pervasive issue that obstructs appropriate socialization of new nurses. Often, nurses bully others to maintain control of their work environment [19]. Organizations that do not protect nurses from bullying are silently promoting unprofessional behavior. Since health care leaders have an obligation to provide a work environment that contributes to the health and well-being of patients and staff, workplace bullying must be addressed.
Each of these challenges individually can be problematic for the new graduate. If they come together without effective strategies for mitigation, then new graduates face a situation in which it becomes extremely difficult to successfully transition to the workplace.
Solutions
Fortunately, the literature offers strategies that can position new graduates for success. Nurse mentoring programs increase new nurses' intent to stay and retention rates [20]. For new graduates to achieve competency, confidence, and autonomy, organizations need a structured approach to developing mentors [21]. In 2000, Morton-Cooper and Palmer [22] introduced a mentorship model that includes 3 phases. In the initiation phase, effective communication skills are needed to establish interpersonal relationships. Next comes the collaboration phase, during which the mentor and the novice collaborate. Finally, during the autonomous phase, the novice is given more independence.
The competency of new graduates increases after the implementation of such a mentorship program [21]. From the moment new graduates begin their residency at Vidant Medical Center, they are paired with a mentor who best matches their personality and has at least 2 years of clinical experience. The mentor or coach is required to complete a didactic nurse coaching class, a 4-hour assessment with their nurse manager, a peer assessment, and 3 annual coaching update classes. The relationship between the new graduate and the coach has proven to be pivotal in the integration of the new graduate into the unit practice environment.
The 2010 report The Future of Nursing [23] recommended a planned program for nurses' transition to practice. Residency programs are vital because graduate nurse turnover can range from 20% to more than 40%, and the financial loss for tertiary care hospitals is estimated at $40,000 for each graduate nurse who leaves during his or her 1st year of practice [24-26]. Vidant Medical Center has offered a new graduate nurse residency program (NGNRP) for the past 6 years. The program is designed to meet the educational needs of nurses during their transition to practice, instill confidence and competence upon entering the clinical setting, standardize orientation, and stabilize retention. While attrition is always a concern for organizations, our program has shown its value by retaining more than 75% of our new graduates beyond 2 years. Of the graduates who started in 2014, 85% are still with our organization, and several have grown into leadership roles as coaches, preceptors, and charge nurses.
NGNRP data are consistent with reports from the Versant RN Residency Program, which showed that the turnover rate decreased as more RN residency cohorts were completed within an organization [24, 25]. The framework of the nurse residency program is evidence-based, and the benefits include reduced turnover, increased engagement of new graduates, improvements in patient safety and satisfaction, acceleration in RN proficiency, and self-confidence [26].
Due to health care reform initiatives and heightened complexities within patient populations, new nurses must be able to synthesize evidence-based information with critical thinking skills; this often requires that nurses attain advanced degrees [27]. The National Academy of Medicine (NAM) presented a compelling case for academic progression in the nursing profession in The Future of Nursing [23]. This report recommended that organizations increase the percentage of nurses with bachelor of science in nursing (BSN) or higher degrees to 80% by 2020. Advanced degrees have been tied to the following competencies: critical thinking skills, ability to implement translational research, heightened leadership abilities, understanding of changes in the health care landscape, understanding of the importance of quality care, understanding of one's role in the continuum of care, improved decision making in the clinical setting, and improved job advancement opportunities [28]. Leaders must be clear about expectations, set goals, and implement processes that support employees' achievement of higher levels of education. The planning should include flexible scheduling, tuition reimbursement, access to computers, and partnerships with universities to facilitate ongoing educational achievement.
In addition to supporting academic progression, involving new RNs in decisions that affect their practice allows them to better manage the complexities of today's health care environment and to cope with stressors. Shared governance gives health care professionals a platform to discuss issues that impact their practice. Nurses who have an active role in making decisions feel empowered, which has been linked to increased staff engagement [29]. Interprofessional decision making also promotes a professional atmosphere that encourages respect and enhances confidence.
Vidant Medical Center has had a robust, shared decision-making council in place for more than 10 years. The focus of this council is to achieve highly reliable quality care by engaging frontline nurses in decision making about nursing professional practice, professional development, standards of care, use of best evidence and research, recognition of nursing excellence, and scholarly inquiry. Unit-based councils drive excellence at the point of care, leveraging the talents of the team to continuously improve patient outcomes, patient experiences with nursing, and nurse engagement. Additionally, frontline nurses participate in self-regulation and reflection in a nursing peer-review process, which is designed to continuously elevate the autonomous practice of nurses. These strategies have been shown to improve patient care and to promote a strong professional practice model for nurses.
Discussion
In addition to the aforementioned solutions, several other issues should be considered. Organizations must have access to reliable supply and demand data—at both the institutional level and the state level—in order to effectively achieve the supply of nurses required to meet the needs of our citizens. Such data are essential as organizations consider new and innovative ways to transition new graduates to the practice environment, to plan for the needs of today, and to forecast the needs of the future.
North Carolina has been a national leader in developing systems to understand the nursing workforce. North Carolina had the first nursing workforce center in the country in 1991; since then, 33 states have adopted this model. In 2008, the North Carolina state legislature did not allocate funding to support the nursing workforce center, and the Cecil G. Sheps Center for Health Services Research became the primary resource for data on the North Carolina nursing workforce.
Finding new and creative ways to expand access to nursing education for qualified applicants is a critical workforce improvement strategy. In 2008, Asheville-Buncombe Technical Community College, Western Carolina University, and the Foundation for Nursing Excellence began a partnership known as the Regionally Increasing Baccalaureate Nurses (RIBN) initiative. With advice from a national team of experts, the RIBN team adapted the Oregon Consortium for Nursing Education model, which admits qualified students into a 4-year educational track with classes provided at both a community college and a partnering university. This partnership between university and community college systems has created additional opportunities for students to achieve a baccalaureate degree, and it makes a career in nursing more accessible to students in rural areas. Academic/practice partnerships like RIBN are important because they bridge the gap left by aging faculty and nonreplenished academic positions. This type of seamless academic progression addresses demand by increasing the number of nurses with baccalaureates or higher degrees. RIBN is coordinated statewide by the Foundation for Nursing Excellence, and it receives financial support from The Duke Endowment, the Jonas Center for Nursing Excellence, the Robert Wood Johnson Foundation, and the North Carolina Area Health Education Centers program.
Conclusion
The new health care environment poses challenges in assuring that the nursing workforce is able to meet the demands of the delivery system and that we have well-prepared faculty to teach the next generation of nursing professionals. In this commentary, we have described some of the challenges and demonstrated some solutions. We cannot control many things about the new paradigm in health care, but strategic implementation of specific programs that focus on building new nursing graduates' confidence and competence can go a long way in helping to make their transition from academia to the practice environment a professionally rewarding time. To support new graduates, organizations must understand that autonomous practice and high-functioning critical-thinking skills develop over time with proper support. Leaders in our industry must adapt and make changes to ensure that we continue to have an adequate supply of qualified nurses to meet the needs of the citizens of North Carolina.
Acknowledgments
The authors wish to thank Ms. Kerry Sewell at the Laupus Health Sciences Library at East Carolina University for research assistance.
Potential conflicts of interest. All authors have no relevant conflicts of interest.
- ©2016 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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