New Graduate Nurse (NGN) Literature Review

New Graduate Nurse (NGN)
New Graduate Nurse (NGN)

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New Graduate Nurse (NGN)

Transitioning from a student into a professional practitioner is a difficult experience for most people. However, the transition experience is especially difficult for graduate nurses who are ushered into a demanding work environment. Most new nurses are shocked at the sheer contrast between student life and work. Just a few weeks after employment, Graduate nurses are expected to take up serious responsibilities including patient care and supervisory duties.

This review explores literature on the New Graduate Nurse (NG) transition experience with the aim of discovering shortcomings in this knowledge area. This research hopes to bridge the gap in knowledge about self-care strategies that NGNs can use as the transition to Registered Nurses.

Background

Waves of research have studied the experiences of nurses as they transit from student to practicing Registered nurses. The first research wave focused on the experiences of individual nurses during the transition phase. The second wave, investigated the effectiveness of interventions meant to support nurses during the transition. Most studies into the experience of New Graduate Nurses (NGNs) used survey and interviews to arrive at their conclusions. The studies reported that NGNs initially found the role of practicing nurse extremely stressing and they reported many challenges.

However, role stress decreased as NGNs gained confidence, obtained clinical support and developed competence (Casey, Fink, Krugman, &Propst 2004; Halfer& Graf, 2006). NGNs described the transition as a difficult time filled with feeling or incompetence, fear of physicians, an overwhelming sense of responsibility, and difficulties in prioritizing, organizing or delegating tasks. Bowles and Candela (2005) carried a study in Nevada that sought to find the attrition rates of new nurse.

It was reported that approximately 30% of NGNs quit their first nursing jobs within the first year of employment. In just two years, 57% had moved from their first jobs. According to Bowles and Candela (2005), the high nurse turnover hinders work productivity, quality patient outcomes and the morale of the staff. Moreover, high turnover means healthcare organization have to incur the cost of rehiring and retraining new nurses to take the roles of those who leave. 

While training more nurses may solve the nurse shortage problem, the problem of deficient patient care and supportive work environment needs to be handled to smooth the nurse transition. Casey et al (2004) found that NGNs are not satisfied with their working environment as they lamented the lack of a consistent preceptor, struggles with authority, a feeling of being undervalued, and workload issues. Chi, Laschinger and Wong (2006) carried out a study on transition among 226 nurses with less than 2 years practice experience.

The study reported similar results to Casey et al (2005); they indicated that there were high burnout rates among new nurses. The nurse complained about the lack of support, limitation of access to resources and opportunities as their main barrier to productivity at the transition phase. However, the job satisfaction outcomes of NGNs improved significantly after the first 18 months of practice. Halfer and Graf (2006) reported high job satisfaction rates among 84 subject of their research.

The two authors argued that nurse started to enjoy their work once they were able to organize their time, prioritize tasks, access resource, understand job expectation, and were made aware of the availability of professional development opportunities.  Studies of nursing thought processes also indicate support the conclusion that the transition is a stressing time for graduate nurses.

According to Pellico, Brewer and Kovner (2009), NGNs’ confidence was initially low as they were unsure about the experience and knowledge , they also feared the interaction with patients as they felt they would not be able to understand their issues. NGNs were also worried about acting autonomously and deciding when it was necessary to call physicians.  By the 9 month, NGNs had significantly boosted their confidence and were able to make competent patient care decisions.

The research wave on NGNs’ transition experience was followed by studies that investigated institutional initiatives to smooth the transition. The second wave was concerned with the preceptor and recognized him/her as a crucial component of the NGN transition process (Bowles and Candela, 2005). This phase of research proposed formal classes; evidence based practice, and guidance and mentoring as crucial precepts of nursing practice. 

The studies proposed that all medical care should be involved in precepting, the presence of a designated preceptor and rewards for those who successfully carry out the preceptor’s role (Bowles and Candela, 2005). Some studies indicated that extended residencies and structured orientation to support the NGN transition improved job satisfaction and reduced the high nurse turnover. NGNs have complained about limited orientation, disorientation, feelings of confusion and loss, overwhelming responsibility as the main barriers to successful transitions.

The difficulties of the NGNs transition to practice are further complicated by other changes in their life (Scott, Engelke and Swanson, 2008). NGNs may have moved to a new town, become married or changed schools. Obviously, the new nurse transition face is fraught with difficult and there is need for support and self-management strategies to handle the stresses of this phase of a nurse’s career.

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Experiences of New Nurses

 NGNs transitioning issues can be classified into four broad themes; demands on nurses, support at the workplace, the control of their role as employees, and perceptions of self efficacy (Bowles and Candela, 2005). 

Workplace Demands

Demand in the workplace on new nurses is a theme that has been explored by many studies. NGNs identified workplace demands such as staff shortages, workload, decision making responsibilities and administrative duties as overwhelming issues (Casey et al, 2004). A survey of newly licensed nurses around the US found that demands relating to time were among the most stressing issues for NGNs. Nurses complained that they were often required to work hard or fast by their supervisors.

Casey et al (2004) also noted that nurses found it stressing to take responsibility for patient care provided by unregulated staff. Unfortunately, nursing has the dubious distinction of being the only profession which requires new practitioners to assume supervisory duties.  Studies exploring the expectations of the multidisciplinary team working with new nurses reveal too high expectations of the (NGNs Waite, 2004). At eight weeks, the multidisciplinary team studied in the research expected new nurses to be able to make specific clinical assessments, be able to use laboratory data, and be able to react to emergencies (Dyess and Sherman, 2009).

In addition, the team expected the NGNs to be knowledgeable about the whole health systems.  Many employers have complained about the deficit of key skills and the readiness of NGNs to deal with the demanding clinical environment.  NGNs critical thinking skills and approaches to medication administration have also been called into question by some scholars.  Romyn et al (2009) argued that NGNs are often responsible for near misses and medication errors as they are not proficient enough handle the medication demands of the job. 

According to Edwards et al (2015), the concerns about the competence of NGNs are not unwarranted as competent performance is not guaranteed while working with graduate nurses.  The lack of a consistent system to measure the performance of NGNs also further complicates the expectation of competence placed upon them. One of the common criteria for measuring competence in nursing is speed and ability to complete specific tasks (Romyn et al, 2009).

Unfortunately, the speed of New Graduate nurses may be quite low and they may not have the same capability to handle patient issues as experienced nurses (Delaney, 2003).  This method of evaluating the performance of NGNs sees their work condemned as unsatisfactory and is often associated with stress among the new graduates joining the workforce.

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Control

Many NGNs report concerns about the control or autonomy of their new roles as practicing nurses. Many new nurses complained that being responsible and accountable to patients was stressing (Delaney, 2003). Duchscher and Cowin (2004) pointed out student nurse roles did little to equip NGNs for the responsibilities awaiting them in practice. Duchscher and Cowin (2004) support the view that patient care decision and outcome responsibilities often overwhelm new nurses. 

However, the reactions of the NGNs varied as some embraced the new responsibilities, but most reported a feeling of being overwhelmed (Delaney, 2003). Researchers have argued that control is a double edged sword in the transition period. For nurses who embrace responsibility and accountability easily, it is exhilarating and exciting. In contrast, control brings about a feeling of anxiety for nurses who are unprepared for the new responsibilities.

NGNs may also suffer disorientation and poor sense of control as a result of unfamiliarity with the practice environment.  NGNs are surprised when they realize that the practice environment is significantly different from the school context (Duchscher, 2001). Chang and Hancock (2003) argue that NGNs can experience as a result of uncertain expectation of the new role which gives rise to role ambiguity.

Support 

Support by supervisors or coworkers plays a significant role in easing the NGN transition process. Often NGNs expend much effort in trying to familiarize themselves with existing workers in their healthcare setting (Casey et al, 2004). Duchscher and Cowin (2004) note that NGNs are in need the support of other members of the multidisciplinary team. Majority of NGNs report that there are adequately supported by preceptors and colleagues (Delaney, 2003).

They also reported that they felt part of the team. However, new nurse could not challenge established ways of doing things as they lacked support in doing this. Nurses also need support from family and friends outside the workplace. In fact, nurse reported that they performed better when they received support from outside the workplace.

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Self-efficacy

Casey et al (2004) reported that NGNs feel incompetent and inadequate as they begin practicing as nurses. Many new nurses report feeling as if they did not posses the necessary skills or knowledge to work as Registered Nurses (Delaney, 2003; Duchscher and Cowin, 2004). NGNs also greatly doubted their clinical competence as they lacked a frame of reference unlike experienced healthcare workers (Duchscher and Cowin, 2004). Duchscher and Cowin (2004) points out those NGNs felt their inadequate knowledge was a serious limitation.  However, NGNs reported higher self-efficacy and confidence scores as they continued to gain clinical experience. 

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Transition Impacts

Job stress

Job stress is one of the most widely reported results of the NGN transition (Delaney, 2003; Duchscher and Cowin, 2004; Twibell et al 2012; Pellico, Brewer and Kovner, 2009). Despite the emphasis on job stress in many studies, few have investigated the intensity of stress affecting NGNs. Chang and Hancock (2003) reported that the transition experience resulted in moderate amounts of stress among NGNs. According to Casey et al (2004), NGNs comfort and confidence is initially very high as the new graduates join the profession, however, it decreases with time in the job.

Fortunately, nurse comfort and confidence starts to increase as they gain experience and peaks one year after commencing practice. Chang and Hancock (2003) reported that nurses experience many stressors during the transition process.  According to the two, the initial stressors include role ambiguity and responsibilities.  After one year of employment, the main stressor is role overload.

Job Satisfaction

One of the most ignored outcomes of NGN transition is the job satisfaction impact. Common studies have emphasized on the challenges experienced during the transition phase but rarely have the satisfying job aspects being explored.  Delaney (2003) reported that some new nurses reported that they found their new roles as practicing nurses satisfying. Nurse’s satisfaction with their work increased when they started to recognize available opportunities for personal growth and development.

Some NGNs reported that it felt exciting to finally take up the role of a practicing nurse.  However, NGNs also reported many dissatisfying elements in their work, these included dizzying pace of work, inadequate staffing and too much autonomy and responsibility (Pellico, Brewer and Kovner, 2009; Casey et al, 2004; Chang and Hancock, 2003). Nurse who were satisfied with their work also were also more intent on staying with their employer.

Further research explored job satisfaction as an independent variable and presented interesting research findings.  Delaney (2003) reported that nurses who were satisfied with their jobs felt a strong sense of belonging to the organization. Satisfaction in jobs was also negatively associated with role stress, role ambiguity and conflict during the transition process (Chang & Hancock, 2003).

Research has also explored outcomes such as turnover intent and nurse turnover. Many of these outcomes increase when there is shortage of nursing manpower.  A high patient:nurse turnover is likely to precede and increase in patient mortality and has been indicated as an accelerator of nurse burnout (Bowles and Candela, 2005). Nurses report that the main causes of high turnover among NGNs are poor work design and emotional exhaustion.

These result support the need to research into self-management strategies that nurses can use to cope to the stressing experiences of the transition process. Twibell et al (2012) have hypothesized that self-care strategies may help nurse achieve higher levels of satisfaction with their jobs.

Interventions to support NGNs

Decades of research have popularized the notion that NGN transition is a process that needs to be addressed (Bowles and Candela, 2005).  Many interventions have been applied to assist is making the transitioning process easy. However, there are few reports of intervention that aim to teach nurses how to self-manage the transition by performing recommended self-care practices. 

Early studies recommended the use of internship programs and preceptor pairing to expose the nurse to the “real world” prior to commencing practice (Bowles and Candela, 2005).  However, the value of preceptor and internship programs have come into questions recently and new research is needed to clarify the value they add to the NGN transition process.

One of the gaps in NGN transition research is the lack of measurement of the effectiveness of interventions to support NGN transition (Bowles and Candela, 2005). Many of the early studies, presented subjective results of the effectiveness of the interventions they were studying.  Later studies in the late 1980s started to include quantitative measures of the effectiveness of the interventions (Casey et al 2004). However, most of the studies failed to measure the impact of the studies on patient outcome. Some of these studies are included in this review.

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Conclusion

The NGN transition process is a well researched area within the nursing profession. Most stakeholders seem to be aware of the problems that face NGNs as they transition into their practice.  Decades of research present findings detailing mostly ineffective interventions to deal with the NGN transition process. One of the most common intervention experimented in research was the use of internship, residencies and preceptors. However, many researchers call into question the usefulness of these interventions in addressing the problems of new nurse’s commencing practice.

This research reveals two reasons why intervention to smooth the NGN transition failed to work despite decades of research.  First, the early interventions were never objectively evaluated and thus the opportunity to gauge their effectiveness and increase their impact was missed. Furthermore, most of the intervention were designed to address problems identified in specific health care settings and were not backed by an understanding of the issues facing NGNs. 

Few of the interventions sought to get to the bottom of the stress experienced by NGNs. Secondly, the interventions failed to take into consideration the many elements of the practice environment. This review presents some of the environmental factors that lead to a difficult experience for NGNs transitioning to practice. NGNs perception of their own abilities and knowledge is among the most stressing factors.

Many NGNs feel incompetent and inadequate when there are starting out. This attitude contrast sharply to the work demand, high expectation, and responsibility that characterize their work environment. Other healthcare workers expect nurses to exhibit the same level of competence and skills as experienced practitioners less than two months after being employed. 

Few nurses are prepared for the sudden responsibility and autonomy they have over patient care decision.  Many find the new responsibility overwhelming and are stressed. However, a substantial number of new nurses are excited and exhilarated to work autonomously. This review also indicates that support from colleagues, supervisors, family and friends are important for a successful transition. Nurses who receive support express confidence in their ability, Skills and knowledge. 

This review has revealed that the NGN transition process can be an extremely stressing period. Many studies point to the stress and emotional distraught that is experienced by NGNs during the transition. Most studies report that new nurse feel overwhelmed by the demands of the new environment, feelings of inadequacy and fear of failure. Very few studies have investigated the possible positive impact of self-care mechanism that may assist nurse’s cope with the difficult transition period. This research will seek to address this gap in research and provide valuable evidence that may be used to improve the NGN transition experience significantly.

References

Bowles, C., & Candela, L. (2005). The first job experiences of recent RN graduates. Journal of Nursing Administration, 32(3), 130Y136.

Casey, K., Fink, R. R., Krugman, A. M., & Propst, F. J. (2004). The graduate nurse experience. Journal of Nursing Administration34(6), 303-311.

Chang, E., & Hancock, K. (2003). Role stress and role ambiguity in new nursing graduates in AustraliaNursing & health sciences5(2), 155-163.

Cho, J., Laschinger, H., & Wong, C. (2006). Workplace empowerment, work engagement and organizational commitment of the new graduate nurses. Nursing Leadership, 19(3), 43Y60.

Delaney, C. (2003). Walking a fine line: Graduate nurses’ transition experiences during orientationJournal of Nursing Education42(10), 437-443.

Duchscher, J. E. B., & Cowin, L. S. (2004). The experience of marginalization in new nursing graduates. Nursing Outlook52(6), 289-296.

Dyess, S. M., & Sherman, R. O. (2009). The first year of practice: New graduate nurses’ transition and learning needs. The Journal of Continuing Education in Nursing40(9), 403-410.

Edwards, D., Hawker, C., Carrier, J., & Rees, C. (2015). A systematic review of the effectiveness of strategies and interventions to improve the transition from student to newly qualified nurse.International journal of nursing studies52(7), 1254-1268.

Halfer, D., & Graf, E. (2006). Graduate nurse perceptions of the work experience. Nursing Economics24(3), 150.

Pellico, L. H., Brewer, C. S., & Kovner, C. T. (2009). What newly licensed registered nurses have to say about their first experiences.Nursing outlook57(4), 194-203.

Romyn, D. M., Linton, N., Giblin, C., Hendrickson, B., Houger Limacher, L., Murray, C., … & Weidner, A. (2009). Successful transition of the new graduate nurse. International Journal of Nursing Education Scholarship6(1).

Scott, E. S., Engelke, M. K., & Swanson, M. (2008). New graduate nurse transitioning: necessary or nice?. Applied Nursing Research,21(2), 75-83.

Twibell, R., St Pierre, J., Johnson, D., Barton, D., Davis, C., Kidd, M., & Rook, G. (2012). Tripping over the welcome mat: Why new nurses don’t stay and what the evidence says we can do about it. American Nurse Today7(6), 357-365.

Waite, R. (2004). Psychiatric nurses: Transitioning from student to advance beginner RN. Journal of the American Psychiatric Nurses Association10(4), 173-180.

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