Graduate Nurse Transition Program

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Graduate Nurse Transition ProgramAuthor(s): Dianne L. Borovies and Nancy A. NewmanSource: The American Journal of Nursing, Vol. 81, No. 10 (Oct., 1981), pp. 1832-1835Published by: Lippincott Williams & WilkinsStable URL: http://www.jstor.org/stable/3462727 .Accessed: 30/04/2014 23:23

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raduate ur se

Transition Program

Coauthor Nancy Newman (1) and new graduate Pat Campbell discuss rotation with RN Colleagues in GNTP.

By: Dianne L. BoroviesNancy A. Newman

A number of programs have beendevised to help the new graduateadapt to the shock-producing situa-tion she encounters when she leavesschool and begins work in a hospital.Not only does the new graduateface a conflict between values and

behaviors she knew as a nursing stu-dent in an educational setting andthose of a new graduate in her firstwork situation, but she also findsthat her theoretical knowledge is oflittle use to her until she no longer isanxious about her clinical skills.

The Graduate Nurse TransitionProgram (GNTP) was designed toassist such nurses to become com-fortable as members of the healthcare team in the realistic work set-

ting of a small to moderate-sizedacute care hospital in Northern Vir-ginia. It is a practical guided experi-ence for beginning level staffnurses, structured o enable them, atits end, to function as beginningstaff in the critical care area.

The nursing administrators'concerns that new graduates cometo the hospital setting with limited

clinical skills were corroborated bya 1978 Nursing Survey Question-naire of the Virginia Hospital Asso-ciation Committee on Nursing, inwhich a majority of the respondentsindicated that associate degree andbaccalaureate nurses lack adequateentry-level clinical skills(l). Carozzacites a Colorado Nurses Associationstatement pointing out serious inad-equacies in the clinical performanceskills of new graduate nurses(2).

In our interviews with severalnursing administrators he point wasmade that generalized orientationprograms usually are not longenough or intensive enough to de-velop adequately the new grad-uate's proficiency in clinical skillsand independent functioning. Arm-

DIANNE L BOROVIES, RN, MSN, is associate direc-tor of nursing, Children's Hospital NationalMedical Center, Washington, D.C.

NANCY A. NEWMAN. RN, MSN. (XRN, is the nurs-ing education coordinator, acute care, Lou-doun Memorial Hospital, Leesburg, Va.

This article is based on the unpublishedmanuscript, A New Graduate Nurse Transi-tion Program-An Application of the Princi-ples of Facts and Planning for IntroducingNew Graduates into the Hospital Organiza-tion, by Ms. Borovies, Ms. Newman, andDawn B. Rigney, RN, MSN.

1832 American Journal of Nursing/October 1981

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strong documents criticisms of suchprograms as too brief and toogeared to a specific institution's pol-icies and procedures(3). In our areaof Northern Virginia, vacancieswere high in critical care staff posi-tions, and while new graduates of-ten expressed a desire to work incritical care areas, most institutions

required at least one year of gener-alized medical-surgical experiencebefore such an assignment. Admin-istrators complained that new grad-uates often came to their small insti-tutions for an initial medical-surgi-cal experience and then left as soonas they qualified for critical carepositions in larger medical centers.

When we planned the GNTP,no transition, internship, or precep-tor programs were being offered inthe Northern Virginia area for newgraduate nurses. While administra-

tors were aware that such programswere costly, they agreed that thelong-range benefits of potential con-tinuing employment might offsetthe short-term costs.

We also talked with recentgraduates from associate, baccalau-reate, and diploma programs whowillingly shared with us memoriesof their first few months as staffnurses at area hospitals. They de-scribed their acclimation as a sinkor swim experience. They saidthey often felt caught in a dichoto-mous situation; they were eager toassume professional roles as patientadvocates, change agents, and caregivers but felt stifled by hang-upsover their lack of experience in clin-ical skills and organizational abili-ties.

They did not feel competent inperforming a majority of clinicalskills and had difficulty integratingtheory to practical experience.

They felt unable to organizeand delegate effectively and effi-

ciently andwere uncertain

aboutthe roles, authority, and responsibil-ities of the various members of thehealth care team.

The program we devised hadits pilot trial at Loudoun MemorialHospital, Leesburg, Va., a 107-bedrural community hospital.

The terminal objective of thesix-month program was stated asfollows:

Having completed the six-month GNTP, the nurse will be

able to meet the criteria for abeginning level intensive care unit(ICU) staff nurse as outlined in theorganization's staff nurse job de-scription.

We designed the program toinclude two modules. Module Awould run for 12 weeks and empha-size generalized medical-surgical

nursing. Upon successful comple-tion of Module A, a participantcould begin Module B, which cov-ered 12 weeks of introductory criti-cal care nursing.

We created an assessment toolthat would determine the skills theparticipant possessed upon entryinto the program as well as indicatethe appropriate experiences re-quired to meet the participant'sneeds throughout the program. Bydeveloping our GNTP clinical skillsassessment in two components-achecklist to correspond with eachmodule with columns for seven dif-ferent assessments-we were able tobuild an ongoing evaluation andfeedback system into the program.

In addition, the Nurse ProfileAssessment was developed so thatparticipants could formulate theirown objectives for each of the twomodules. Leypoldt stresses he valueof learners' setting their own goalsas well as the need for instructorsand learners to evaluate progressperiodically toward attainment ofthese goals(4).

A review of internship and pre-ceptorship programs reported in thenursing literature showed a varietyof ratios of didactic to experimentalhours. In the GNTP, each moduleincludes clinical experience on allthree shifts with a 1:2 ratio of class-room to clinical practice.

Clinical experience beginsbriefly during the hospital's gener-alized orientation program, which ispart of Module A. Participants'

eight-hour-day experiencewith

pa-tients begins the third week andcontinues throughout the GNTPwith the exception of time spent inclassroom, group, or counseling ses-sions. The number of patients as-signed gradually increases, and theamount of unit responsibility dele-gated to the new graduate advancesas the individual progresses hroughthe program. Experience includesweekends and rotation to all threeshifts. Participants are not counted

in unit staffing patterns but, rather,as additional nurses assigned to unitsto acquire needed skills and experi-ence.

The clinical experience pro-vided in both modules is augmentedby continuing clinical supervisionand support from an RN Colleague.In the medical-surgical module, the

colleagues remain on their respec-tive shifts while the participants ro-tate. In the intensive care module,however, the colleagues and partici-pants rotate together. The colleaguefunctions as the new graduate'smentor while in the clinical area. Itis the new graduate's responsibilityto seek out assistance whenever shefeels the need for it. Such guidanceand support strengthens self-confi-dence and feelings of responsibilityand encourages initiative in the useof support resources(5).

The RN Colleagues receive anorientation to the GNTP and to thephilosophy of the colleague concept.While no monetary incentive is of-fered to the RN Colleagues, nursesfunctioning in this role experienceenhanced self-worth and a feelingof contributing to the profession.Colleagues have the option of keep-ing a log of prn entries of concernsand positive or negative commentsor both regarding the GNTP; thisserves as a communication tool be-tween the colleagues and the staffdevelopment instructor responsiblefor coordinating the program. Addi-tional classroom and clinical contentsuggested by the RN Colleaguesmay be incorporated.

We have found recent grad-uates extremely receptive to theidea of a daily diary as a way tokeep a running anecdotal account ofevents and activities. As part of thisprogram, the diary serves as a basisfor discussion at diary-sharing ses-sions or in one-to-one conferencesbetween each

participantand

thestaff development instructor. Greenand Stone point out that often dia-ries can provide clues to unthought-of issues or problems for formal fol-low-up at subsequent times(6).

Six 90-minute reality shock rapsessions are held weeks 13 through18 to discuss, in a supportive envi-ronment, topics related to difficul-ties encountered as new graduatesadapt to the staff nurse role. Eachparticipant must attend a minimum

American Journal of Nursing/October 1981 1833



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the program. By the end of ModuleA, the nurses appeared confidentand comfortable with their assign-ments.

The fear and anxiety of thetransition nurses was apparent with-in the first two weeks of clinicalassignments. Because of their anxi-ety, diary-sharing sessions were heldat the beginning of all class meet-ings before formal instruction could

begin. They felt overwhelmedabout facing crisis situations beforeresolving their own fears and anxie-ties about their competency. Theyfound that diary-sharing sessionshelped allay their anxieties by pro-viding opportunities for just get-ting it out. In our small hospitalsetting, it was evident that realityshock arrived sooner than antici-pated. We have continued to offerthese sharing sessions throughout

Module A on an optional weeklybasis.

By the time of the scheduledreality shock rap sessions n ModuleB, participants had resolved initialanxieties and fears and were morereceptive to discussing broader con-cepts of conflict resolution and roletransformation. We believe that thecombination of the diary-sharingsessions and the reality shock rap

sessions contributed greatly to thepositive psychosocial adaptation ofthe new graduates. Periodic evalua-tions of participants' progress werean integral part of the program.Evaluations included the following:

* Joint review of the GNTPClinical Skills Assessment by theparticipant, the RN Colleague, andthe staff development instructor atweeks 6, 9, 12, 18, 21, and 24.

* Joint review of the Nurse

Profile Assessment by the partici-pant, the RN Colleague, and thestaff development instructor atweeks 6, 9, 12, 18, 21, and 24.

* Joint review of the profes-sional performance appraisal by theparticipants, the RN colleague, ahead nurse, and the staff develop-ment instructor at weeks 12 and24.

* Completion by RN Col-

leagues of a concise evaluation ofthe GNTP and participants at weeks6, 9, 12, 18, 21, and 24.

* Completion of a subjectiveevaluation of Module A and of Mod-ule B by participants at weeks 12and 14 respectively.

* Completion of a subjectiveevaluation of the GNTP by the RNcolleagues at the end of theGNTP.

* An evaluation conferencewith nursing administrative person-nel at the end of the GNTP to dis-

cuss the strengths, weaknesses, andoutcomes of the program and itsparticipants.

This program was not designedto resolve issues involving the rela-tionship between educational pro-grams and the skill levels of newgraduates and the expectations ofemploying agencies. The GNTPwas designed to provide assistanceto participants n the transition romstudent to staff nurse. It also wasplanned as a potential recruitmenttool and an effort that would de-crease attrition rates of new grad-uates.

We believe that the GNTP aidsnew graduates in gaining clinicalexperience and a realistic view ofhospital nursing by assisting andsupporting them during the criticalearly months of their careers.

References1. Virginia Hospital Association, Committee on

Nursing. Analysis of 1978 Nursing Survey

Questionnaire, Part1.

Richmond,The Associa-

tion, Feb. 1979, p. 87.2. Carozza, Virginia, and others. An experimental

educationally sponsored pilot internship pro-gram. JNE 17:15, Nov. 1978.

3. Armstrong, M. L. Bridging the gap betweengraduation and employment. J.Nurs.Adm.4:42-43, Nov.-Dec. 1974.

4. Leypoldt, M. M. The teaching learning processwith adults. Adult Lead. 16:213, Dec. 1967.

5. McGrath, B.J., and Koewing, J. R. A clinicalpreceptorship for new graduate nurses.J.Nurs.Adm. 8:13, Mar. 1978.

6. Green, J. L., and Stone, J. C. Curriculum Eval-uation: Theory and Practice. New York,Springer Publishing Co., 1977, pp. 197-198.

American Journal of Nursing/October 1981 1835


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Graduate Nurse Transition Program