Essay about nursing education

Lila Leanne Bennett, MSN, RN; Alan Grimsley, PhD; Linda Grimsley, PhD, RN; and Jan Rodd, MSN, RN

The Gap Between Nursing Education and Clinical Skills

Abstract: New graduate nurses are often stressed in the early months of their first position following graduation. The researcher examined whether new graduate nurses were ready for the workplace or if there a gap between nursing education and clinical skills, causing new graduates to feel less confident and new supervisors/employers to be frustrated with the graduates’ lack of readiness to be part of the nursing team. The concern was whether the new graduates had acquired the necessary clinical skills while in their nursing education programs in order for them to be a full team member upon graduation. The model used to examine both important areas of education and practice was Benner’s (1984) model of skill acquisition. Thirty-three new graduates with less than one year of experience participated in the study.

Key Words: Clinical Skills Development; Clinical Skills of New Graduates; Nursing Expertise; Ben­ ner ’s Model of Skill Acquisition

Introduction

Transition from nursing student to Registered Nurse has proven to be a difficult transition. Some new graduate nurses are not adequately prepared to assume the role of a nurse without more

clinical experience. New graduate nurses face many different challenges and enormous pressure to meet professional expectations.

Health care consumers have expectations as to how their care should be provided which can have a negative effect on new graduate nurses whose skills are not yet efficient. Additionally administration pressures nurses to provide efficient, effective and profitable care, which places pressure on nursing programs to provide work-ready graduates. This research reviewed nursing education and the readi­ ness of clinical skills of new graduate nurses.

Expertise in clinical nursing skills is necessary to provide quality care. From an educational stand­ point, the amount of knowledge needed to care for patients in a safe and effective manner requires new graduate nurses to embrace additional learning resources outside of the traditional learning environments. According to Dadgaran, Parvizy and Peyrovi (2012), the clinical education a nurse receives is predictive of how a nurse will perform in the clinical setting.

Researchers found the education of nurses did not always prepare them for the different areas of the hospital and there is a difference in what the students learn and how that education is used in an active clinical environment. Nursing students do not select clinical placements during nursing school and are not responsible for a full load of patients so they do not acquire the skill of dealing with differ­ ent patients with different issues at the same time.

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Nurse educators must adapt to a changing healthcare environment that includes teaching technology for medical records/charting, changing patient popula­ tions and an increasing number of disease processes. Cheng, Tsai, Chang and Liou (2014) stated many administrators are not confident with the new gradu­ ates’ ability to provide safe, efficient care, indicating a possible need for an internship to transition from school to the workplace.

Nursing programs that implement a transition period during school which allows students to work in a clinical environment with a full patient load alongside an experienced nurse may help increase clinical knowledge and competence of the new grad­ uates. Transition may provide new graduate nurses increased confidence. There is stress on new nurses to familiarize themselves with their new environ­ ment while they portray themselves as competent, when in reality, the new nurse is still learning. New graduate nurses are shocked to learn the extent of their duties when they begin working in the clini­ cal area (Cheng et al., 2014).This reality shock is experienced in four stages. In phase one new gradu­ ate nurses are excited about having a paying job and are in a euphoric state (Cheng et al., 2014). In phase two reality starts to set in and new nurses realize the work environment is much different than the clinical experience from school. In the third phase, the stress level begins to lower because new nurses begin to understand what is expected of them. In stage four, new nurses develop a plan and begin to cope with the stress and learn the duties of their job and how to perform efficiently (Cheng et al., 2014). Stress is part of nursing, but is increased due to the expecta­ tions to swiftly acquire their new roles and respon­ sibilities, learn the difference between theory and practice and join a team where they must work well with others.

Bjerknes and Bjprk (2012) explained that new nurses were not educated in the clinical environ­ ment to be adequately prepared and other nurses, patients and administrators had unrealistic expecta­ tions of their abilities. Many facilities have created mentorship to provide graduates more time to gain confidence in their ability to provide patient care. According to Dyess and Sherman (2009), many new nurses assume roles in specialty areas that require extensive knowledge in those areas which are above the level they received in school, requiring an ex­ tended orientation period.

New graduate nurses employed in rural areas are expected to take on many different duties with­ out guidance from another nurse. The new gradu­ ate nurse in the urban area may better perform with some autonomy because they know they are not alone if they have questions (Dyess & Sherman, 2009) . Nurses who start out in urban areas have re­ sources from multiple nurses and physicians who are not available to those in the rural setting. In many instances, the nurses in the rural area are working basically alone (Duchscher, 2009).

Duchscher (2009) stated that new graduate nurses face challenges that affect their performance during the transition from school to employment. These challenges include level of knowledge, physi­ cal demands placed on them, stress of acceptance by their peers and adapting to culture of their new en­ vironment. Concern about the competency of nurses comes from an increase in morbidity and mortality rates of hospitalized patients in the United States. There is a high expectation on nurses, new and expe­ rienced, to provide their patients with both efficient and safe care.

Do new graduate nurses lack the appropriate education? According to McHugh and Lake (2010), the teaching methods used by professors in nursing programs have a huge effect on students’ learning to make correct clinical decisions while employing critical thinking. Clinical experiences are to help students learn the psychomotor skills that the new graduate nurse must have, skills also influenced by the teaching methods which are employed. Recruit­ ing nurses from select programs educated with all the necessary tools can help to bridge the gap; how­ ever, many programs produce new graduate nurses with limited skills to apply in the real world.

Using a multi-level conceptual framework to guide the study, the researcher examined the educa­ tion of new graduate nurses to include theoretical and clinical areas that influence competence. The competence of new graduates affects their ability to practice effectively. New nurses need their peers and patients to be understanding regarding their skills. Benner’s model of skill acquisition can be used to examine both education and practice areas and con­ sists of five stages of clinical competence (Landers, 2010) .

Novices are newly graduated nurses entering the clinical area with basic knowledge learned from

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clinical and laboratory practice with little knowl­ edge of the requirements of nurses in a clinical environment. Strict guidelines and directions from a preceptor are needed ensure duties are performed as expected by the institution. Advanced beginner nurses have begun to adapt to their environment and have a marginally acceptable skill level they can use in textbook situations; however, they continue to need guidance from a preceptor. Competent nurses have acquired some degree of mastery and can respond under pressure in the clinical environment but lack the speed necessary to complete their tasks in a timely manner. Proficient nurses have learned how to handle situations as a whole and can manage clinical situations using inductive reasoning. They have goals and are achieving them with a knowledge base built up over years of experience. Expert nurses can make decisions without guidance and solve complex problems rapidly all while giving effective and efficient nursing care.

Preceptors are pivotal in the learning process so that nursing students model excellent care after watching their educators complete the task the cor­ rect way. Nursing student then move to the clinical practice environment with the knowledge to provide nurturing care.

The hypothesis for the study was: New graduate nurses are not ready for the workplace because of a gap between nursing education and clinical skills.

The following definitions applied to this study. 1. Expertise is the possession of expert skill or

knowledge in a particular field that allows one to proficiently perform specific tasks.

2. Nursing education is the transmission of both practical and theoretical knowledge to develop competent nurses.

3. Nursing practice is the act of protecting and pro­ moting good health while preventing illnesses and injuries and entails application of knowledge acquired.

4. Quality care aims at increasing the likelihood of desirable and consistent health outcomes with current knowledge within a given profession.

Nurses are evaluated for the care they provide, not only by administrators but also by patients for whom they care. They are expected to provide excel­ lent, competent care at all times. It is vital that edu­ cational institutions offer a curriculum that provides

nursing students with the educational experience that provides them the tools to move into the clinical practice field at a competent level.

LITERATURE REVIEW Nursing professionals provide services for

complex patients in many different types of facili­ ties. Upon graduation, use of clinical and practical skills along with good clinical judgement will give new nurses the ability to smoothly transition into the workplace. Decisions for patients come with a great deal of responsibility which may cause stress on new graduates who do not feel prepared. Chal­ lenges include psychological stress along with the physical stress of learning a new job. Certain things may need to be implemented to narrow the gap such as a longer orientation, more hands-on training or a mentorship program.

In the workplace, new graduates have numerous transition challenges that affect their performance (Duchscher, 2009). Those challenges are related to physical, social, intellectual, cultural and psycholog­ ical changes and come about as new graduate nurses adjust to the new environment. New nurses may ex­ press their stress through emotions and feelings such as nervousness, insecurity, self-doubt and feelings of inadequacy.

Duchscher revealed a gap between nursing education and clinical skills when new graduates move into professional workplaces; a failure of the educational program curricula not linking with workplace expectations, thus new graduates not be­ ing adequately prepared to join the workplace. Such negative effects may diminish the delivery of high- quality healthcare by new graduates.

Numminen et al. (2014) analyzed whether nurses’ education met the requirements for practice in the working field. They examined reviews from nurse administrators and nurse lecturers about the new graduate nurses’ professional abilities, who con­ cluded that skills among the new graduates did not compare to those of experienced nurses. They sug­ gested that efficient collaboration between instruc­ tors and practice administrators before the students completed their education could help ensure new graduate nurses were ready for the workplace. They concluded that the lack of collaboration between the instructors and administrators was among the key factors contributing to the emergence of the rift

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between clinical skills and nursing education in new graduate nurses.

Wu, Fox, Stokes, and Adams (2012) sug­ gested that new graduate nurses were affected by work-related stress which interfered with safety precautions and made the nurses commit numerous medication errors. The authors stated that the reason for the work-related stress was inadequate prepared­ ness of the nurses after completion of their educa­ tion. Further, Wu et al. showed that as most nurses transitioned into the workplace they did not exhibit adequate skills to enable them to operate equipment in the workplace, reflecting a gap between education and the work place environment.

Yeh and Yu (2009) studied causes of work stress and factors that influenced new graduates to stay or quit work. The authors suggested that the first month was most stress intensive for the new gradu­ ate nurses, and in the second month they considered quitting. Moreover, new nurses who exhibited the greatest gap were twice more likely to quit than properly educated nurses. The gap of new graduates was a result of inadequate mentorship and train­ ing programs in the nurses’ curriculum, inadequate support from nurse administrators in assisting new nurses to adapt to the new workplace, as well as inadequate clinical practical for the students. The study also supported that medication errors and low-quality health care were derived from unpreparedness of the new nurses.

McAllister, Happell, and Flynn (2014) attempted to establish attributes and competencies of nurse graduates through examining reviews of Austra­ lian nursing managers in a comprehensive nursing program. They suggested that a gap was responsible for the global shortage of highly qualified nurse graduates who were well versed in knowledge, at­ titudes and scientific skills. Much of the Australian curriculum lacked the practice perspective and relied heavily on the academic perspective. They revealed that curriculum issues also contributed to the gap in practical skills and nursing education among new graduates leading to a decrease in the quality of health care.

Watt and Pascoe (2013) examined experience in a university-owned clinic and how it affected the perception of new graduates in the nursing pro­ fession. They reported that nursing students who were schooled in an institution owned by a hospital thought they were ready for the profession after

graduating. The reason was that the students were exposed to the culture, environment and administra­ tion systems in hospitals or clinics. Interacting in those environments and learning the different sys­ tems instilled confidence and skills into students, preparing them for practice. Those phenomena enhanced new graduates’ ability to access and utilize medical information and resources at the workplace.

Saifan, AbuRuz, and Masa’deh (2015) sought to establish the reasons as well as identify solutions for the existence of a gap between education and the workplace. They stated that student nurses thought that the presence of underqualified lecturers was a critical factor that contributed to the gap between clinical practice and nursing education. Students stated that there was an increased lack of interaction between instructors who teach practical lessons and those who teach theory lessons, which interfered with their continuity of the educational process. As a result, nursing students possessed inadequate sup­ port through their clinical training.

METHODOLOGY The researcher utilized a quantitative descrip­

tive study design for data collection from newly graduated nurses. This study explored whether there was a perceived gap between nursing education and level of clinical skills acquired and whether graduate nurses were prepared for challenges that are part of their job.

Participants in the study included 37 nurses who were new graduates and had been in a clinical set­ ting between three months and one year. First-year nurses can describe their experiences well because they are still in the period of transition from college training into places of work. Participants had the ability to describe the experiences and challenges encountered in the clinical area.

The researcher completed human subjects train­ ing and adhered to all ethical considerations. The re­ searcher sought informed consent from participants before obtaining any information. Participants who did not complete the Consent Form were excluded from the study. The researcher protected study subjects by keeping all information confidential with only the researcher and the committee having access.

The researcher used a self-developed survey based on previous studies to identify perceived gaps existing between nursing education and the set of skills acquired in school and whether nurses were

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well prepared for their work. The researcher used Survey Monkey® to collect data. In addition to the demographic data, the survey consisted of 9 ques­ tions with “yes” or “no” answers.

Data were collected over a period of 10 days to allow participants the opportunity to respond at their convenience. Data were analyzed using Survey Monkey® software that categorized information in graphs and charts.

Research Findings The study used a self-reporting questionnaire to

determine if graduates were ready for the workplace A networking sample was collected from practic­ ing nurses using Facebook. The study had 37 re­ spondents. Inclusion criteria were registered nurses

with between 3 months and 1 year of experience. Exclusion criteria included registered nurses with over one year experience. Demographic data col­ lected were gender, age, length of practice, specialty, region of country, prior experience and education. Most respondents were female (84%); with 16% male. There were 7 different age ranges from 18-75+ years; most were in three age ranges, 25-34 (n=9, 24%); 35-44 (n=12; 32%); and 45-54 (n=7; 18%).

Respondents’ time as a nurse, practice specialty and region of the country where they were employed were requested. Time as a nurse ranged from 3-6 months (n= 14; 38%), 6-9 months (n=2; 7%), and 9-12 months (n=21; 55%). Specialties included medical-surgical (n=12; 32%), pediatrics (n=9; 24%), OB (n=6; 16%), ICU (n=4; 11%), and ER

Table 1. Education Preparation

Variable n %*

Educationally prepared for solo practice upon graduation?

Yes 18 54.6 No 15 45.6

Adequate “hands-on” in clinical? Yes 21 63.6 No 12 36.4

Under-trained for first job? Yes 12 36.4 No 21 63.6

Were critical “hands-on” skills not taught in school?

Yes 28 84.9 No 5 15.1

Should schools include preceptorship in last year?

Yes 31 93.9 No 2 6.1

Other factors hindering you from providing competent care?

Yes 10 30.3 No 23 69.7

Mentoring program at your institution? Yes 14 42.4 No 19 57.6

Individual factors influencing your competence as new nurse?

Yes 21 63.4 No 12 36.4

Organizational factors influencing competence as new nurse?

Yes 20 60.6 No 13 39.4

N = 33 *Note - Numbers may not equal 37; Percentages may not equal 100.

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(n=6; 16%). Although regions of the country listed were North, South, East, and West, the respondents came from the South (n=36; 97%) and East (n=l; 3%) only.

Respondents were asked if they had worked as an assistant or nurse tech before becoming a nurse as well as their level of education. Slightly more had worked as an assistant (n=20; 54%) than those who first started as a nurse (n-17; 46%). Education levels were also diverse with 17 (46%) having an Associ­ ate degree; 11 (30%) Bachelor’s degree; 8 (22%) Licensed Practical Nurse, and 3 (8%) Certified Nurs­ ing Aide.

The questions about educational preparation required “yes” or “no” responses and are addressed in Table 1.

DISCUSSION AND CONCLUSIONS The respondents were nurses employed for

three months to one year. Findings were similar to Duchscher’s (2009) who stated that nurses had many challenges which caused anxiety, insecurity, and self-doubt to which the new nurse must learn to adjust. This finding was not surprising.

Most respondents felt they were provided enough “hands on” clinical experience in nursing school; findings opposite those of Wu et el. (2012). The e findings may be attributed to the area in which the new nurse was employed and the graduate’s pre­ ceptor. Nurses who were not in a specialty area may have felt more prepared.

Most respondents stated they were not under­ trained for their first job; findings similar to those of Watt and Pascoe (2013). The researcher found the data to be interesting as it indicated the nurses’ readiness may be linked to whether they were em­ ployed in a hospital facility where they trained.

An overwhelming majority of respondents felt some critical hands-on skills were not taught in nursing school; findings supported by Saifan et al. (2015). Theory taught in the classroom is not always being transferred to the clinical training environ­ ment, a disconnect between the educators in the two areas. Ninety-four percent of the respondents felt that a preceptorship should be included in nursing school as it would provide real-world experience in the clinical environment. Watt and Pascoe (2013) re­ ported increased readiness in students whose school was owned by a hospital.

Most respondents stated not have a mentoring program at their institution which could contribute to the gap between education and clinical environ­ ment. Watt and Pascoe (2013) noted the importance of the students being in the hospital environment was exposure to the hospital and administration cul­ ture.

Of factors that influenced the competence of the new graduate nurse, chief was stress. The way in which the nurses handle stress may affect how suc­ cessful they are in their job. Organizational factors also influenced the competence of new graduates but was not surprising as new nurses are expected to begin knowing what experienced nurses know. Yeh and Yu (2009) postulated that the gap was created because administration failed to assist new nurses adapt to their new environment.

Several areas can help with the transition of the graduate nurse to the workplace environment. Theory and clinical educators must work together to prepare the nurse. The administration has a vital role in providing support necessary to reduce stress. The need for a preceptorship program during the last semester of nursing school may be a viable option. New graduate nurses should not be expected to be an expert. They need patients and staff to be understanding of the learning process so that stress will be reduced.

Further research should be pursued with a larger sampling of the population and more detailed ques­ tions to better determine the reasons for the gap be­ tween nursing school skills and the first workplace. A broader spectrum of the nursing population would help determine if the problems were unique to the South or generalized across the nursing spectrum. This study examined if new graduate nurses were ready for the workplace based on Benner’s Model of Skill Acquisition. It appeared there were areas where the nurses felt confident and there continued to be areas of concern. More research is needed to deter­ mine if a preceptorship would improve new nurses’ readiness for the workplace.

Education is an important aspect of preparing the nurse for real life situations. However, education must include nursing theory and nursing practice that are linked together by excellent instructors in both areas. New graduate nurses need to feel confi­ dent and prepared when undertaking their roles in a life-changing environment.

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REFERENCES Bjerknes, M., & Bj0rk, I. (2012). Entry into Nursing:

An Ethnographic Study of Newly Qualified Nurses Taking on the Nursing Role in a Hospital Setting. Nursing Research and Practice, 1-7. http://dx.doi. org/10.1155/2012/690348

Cheng, C., Tsai, H., Chang, C., & Liou, S. (2014). New Graduate Nurses Clinical Competence, Clinical Stress, and Intention to Leave: A Longitudinal Study in Taiwan. The Scientific World Journal, 1-9. http://dx.doi. org/10.1155/2014/748389

Dadgaran, I., Parvizy, S., & Peyrovi, H. (2012). A Global Issue in Nursing Students Clinical Learning: The Theory Practice Gap. Procedia - Social and Behavioral Sciences, 4 7 ,1713-1718. http://dx.doi.Org/10.1016/j. sbspro .2012.06.888

Duchscher, J. E. (2009). Transition shock: The initial stage of role adaptation for newly graduated Registered Nurses. Journal o f Advanced Nursing, 65(5), 1103-1113.

Dyess, S., & Sherman, R. (2009). The First Year of Practice: New Graduate Nurses Transition and Learning Needs. Journal o f Continuing Education in Nursing, 40(9), 403- 410. http://dx.doi.org/10.3928/00220124-20090824-03

Landers, M. (2010). The Theory-Practice Gap in Nursing: The Role of the Nurse Teacher. Journal o f Advanced Nursing, 52(6), 1550-1556. http://dx.doi.org/10.1046/jT365- 2648.2000.01605.x

McAllister, M., Happell, B., & Flynn, T. (2014). Learning Essentials: What Graduates of Mental Health Nursing Programmes Need to Know from an Industry Perspective. Journal of Clinical Nursing, 23(24), 3449- 3459.

McHugh, M., & Lake, E. (2010). Understanding Clinical Expertise: Nurse Education, Experience, and the Hospital Context. Res. Nurse. Health, 55(4), 276-287. http:// dx .doi .org /10.1002/nur.20388

Numminen, O., Laine,T., Isoaho, H., Hupli, M., Leino-Kilpi, H., & Meretoja, R. (2014). Do Educational Outcomes Correspond with the Requirements of Nursing Practice: Educators’ and Managers’ Assessments of Novice Nurses’ Professional Competence. Scandinavian Journal of Caring Science, 28(4), 812-821.

Saifan, A., AbuRuz, M. E., & Masa’deh, R. (2015). Theory Practice Gaps in Nursing Education: A Qualitative Perspective. Journal o f Social Sciences, 11(1), 20-29.

Watt, E., & Pascoe, E. (2013). An Exploration of Graduate Nurses’ Perceptions of Their Preparedness for Practice After Undertaking the Final Year of Their Bachelor of Nursing Degree in a University-Based Clinical School of Nursing. International Journal o f Nursing Practice, 79(1,23-30.

Wu, T.-Y., Fox, D. P , Stokes, C., & Adam, C. (2012). Work- Related Stress and Intention to Quit in Newly Graduated Nurses. Nurse Education Today, 36(6), 669-674.

Yeh, M.-C., & Yu, S. (2009). Job Stress and Intention to Quit in Newly Graduated Nurses During the First Three Months of Work in Taiwan. Journal o f Clinical Nursing, 78(24), 3450-3460.

Lila Leanne Bennett, MSN, RN, corresponding author, is a 2017 graduate o f the M aster’s in Nurs­ ing Program, Albany State University, Albany, Geor­ gia. Alan Grimsley, PhD, Linda Grimsley, PhD, RN, and Jan Rodd, MSN, RN are currently Albany State University faculty members. Ms. Bennett may be reached at: [email protected]

CALL FOR REVIEWERS

The ABNF Journal, official journal of the Association of Black Nursing Faculty Inc., has issued a call for reviewers. Anyone interested on serving on the Editorial Review Board, please call or e-mail the editor:

Dr. Linda Amankwaa, FAAN Department of Nursing Albany State University

Albany, GA 31705 [email protected]

229-291-4292 (Office)

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