TRANSITIONING FROM NOVICE TO COMPETENT:

WHAT CAN WE LEARN FROM THE LITERATURE

ABOUT GRADUATE NURSES IN THE
EMERGENCY SETTING?
Author: Anna Maria Valdez, RN, PhD, CEN, Salida, Calif
Earn Up to 10 CE Hours. See page 495.
S
everal significant issues and trends in nursing are im-
portant to consider when projecting the future of
emergency nursing education. The first and arguably
most significant issue is the shortage of registered nurses,
which is predicted to steadily increase during the next de-
cade.
1
The trend of experienced nurses leaving the patients
bedside due to retirement, work environment dissatisfac-
tion, or both, has contributed to a significant shortage of
skilled nurses available to fill acute care vacancies. To ad-
dress this growing shortage of Americas nurseswhile
meeting the changing needs of an increasingly complex
population of patientshealth care organizations are mak-
ing every effort to recruit and retain talented nurses.
With the pool of candidates being limited and nursing
vacancies approaching 9% across the United States, hospi-
tals are turning to schools of nursing to produce compe-
tent graduate nurses (GNs) to meet current and projected
health care demands.
1
In an effort to address the crisis level
staffing challenges experienced on a daily basis in U.S. acute
care hospitals, these neophyte nurses are being recruited
for and hired to practice in highly specialized patient care
units, including the emergency department. In spite of re-
search documenting the plethora of stressors faced by nov-
ice and advanced beginner nurses while assimilating into
the clinical environment, no standardization of the GN
orientation process has occurred.
2-7
Newly graduated nurses often experience a culture
shock when transitioning from the academic ideal of nurs-
ing to the clinical reality of nursing practice. Rapid immer-
sion into the modern-day acute care work environment
and feelings of inadequacy lead many new graduates to feel
overwhelmed, unsupported, and disillusioned.
4
Known
stressors that accompany entry into practice, coupled with
the high-stress, fast-paced, life-and-death environment of
the emergency setting, place the new graduate at increased
risk for failure to thrive in clinical practice.
A number of resources are available that identify core
knowledge for nurses developing competence in the emer-
gency setting.
8,9
ENA has invested significant resources
to develop competency-based educational programs (ie,
Emergency Nursing Orientation Course, Trauma Nurse
Core Curriculum (TNCC), and ENPC) for nurses practic-
ing in the emergency setting. These resources are critical
elements of the postregistration education for ED nurses;
however, they are designed to be utilized as a part of an
individualized, clinically based, blended learning program.
Rather than recapitulating what expert emergency nurses
already have identified as core and developmental compe-
tencies for ED nurses, this article will summarize what is
known about the GN experience and provide recommen-
dations for nurse educators that are charged with designing
an educational plan to facilitate the transition from novice
to competent in the emergency department.
Theoretical Foundation: Novice to Expert Practice
According to Benner,
10
the transition from novice to expert
occurs as a result of experiential learning in the clinical
practice setting. In her seminal publication, From Novice
to Expert: Excellence and Power in Clinical Nursing Practice,
Benner describes a body of practical knowledge embedded
in nursing practice.
10
Utilizing the Dreyfus Model of Skill
Acquisition applied to the nursing profession, Benner de-
scribes the process of clinical judgment and skill develop-
ment at 5 levels of proficiency: novice, advanced beginner,
competent, proficient, and expert.
Anna Maria Valdez, Sacramento Chapter, is director of clinical services,
REACH Air Medical Services, Santa Rosa, Calif.
For correspondence, write: Anna Maria Valdez, RN, PhD, CEN, 451 Avia-
tion Blvd, Santa Rosa, CA 95403; E-mail: anna_valdez@mediplane.com.
J Emerg Nurs 2008;34:435-40.
Available online 15 May 2008.
0099-1767/$34.00
Copyright 2008 by the Emergency Nurses Association.
doi: 10.1016/j.jen.2007.07.008
C L I N I C A L
October 2008 34:5 JOURNAL OF EMERGENCY NURSING 435
NOVICE
Novices in nursing are beginners with no prior experience in
the nursing practice they are expected to perform. During
this phase of skill acquisition, the learner has negligible con-
textual understanding of the theories and concepts they
are being taught. To guide clinical practice and patient care
experiences, the novice learns measurable nursing rules
and procedures. A lack of situational context with which
to correlate rule application limits the novice nurse and gen-
erally results in an inflexible, universal approach to clinical
practice. This level of proficiency is frequently seen in the
prelicensure nursing student, although even an experienced
nurse entering a new specialty role may function at this
proficiency level.
10
New graduate nurses enter the acute care
setting with some contextual understanding of the rules
and procedures of clinical nursing; however, often these
nurses have not had sufficient exposure to the emergency
setting to practice beyond the novice level.
ADVANCED BEGINNER
The advanced beginner has been exposed to patient situa-
tions of sufficient variety and complexity to progress to a
marginally acceptable level of performance. Patient situa-
tions may have been direct patient care or exposure through
mentoring in the clinical setting. The rules and procedures
of nursing practice are no longer context free for the ad-
vanced beginner. At this stage of experiential learning,
the nurse is beginning to see the whole clinical picture
and is able, with assistance, to recognize unique aspects or
characteristics of individual patient situations.
10
Nurses at
this level of skill acquisition frequently are asked to func-
tion independentlyoften without a sense of comfort or
confidencein the acute care setting. During this phase
of the experiential learning process, nurses need support
and mentoring by experienced nurses who have reached
at least the competent level of skill and performance.
10
COMPETENT
Competent nurses have a broader perspective; they are able
to see nursing actions in terms of long-range patient care
goals. During this phase of skill acquisition, the nurse plans
care based on identified priorities rather than providing
stimulus-responsebased interventions. According to Benner,
10
the competent nurse lacks the speed and flexibility of the
proficient nurse; however, at this level of aptitude, the nurse
is able to cope with and manage many of the more chal-
lenging contingencies of clinical nursing practice. Although
there is no established time frame that can be applied to
these phases of skill acquisition, the competent nurse gen-
erally has 2 to 3 years of experience in an analogous clini-
cal setting.
10
PROFICIENT
At the proficient level, the nurse effectively perceives the
entirety of the clinical situation. Rather than responding
to aspects of patient care, this level of clinician usually is
guided by substantial practical experience, an understand-
ing of the key principles of nursing, and basic human
needs. The proficient nurse has an experienced-based abil-
ity to recognize nuances in clinical situations and can iden-
tify when the expected normal picture does not occur. A
holistic understanding of clinical situations provides the
proficient nurse with the ability to make clinical decisions
without the need to consult learned rules or procedural
guides. The proficient nurse typically has 3 to 5 years of
experience in a given clinical setting.
10
EXPERT
The expert practitioner does not rely on analytic principle
such as rules, guidelines, or maxims to connect his or her
understanding of a patient situation to the appropriate nurs-
ing action. This is not to say that the nurse does not utilize
skilled analytical abilities when necessary. However, the
expert is a highly experienced and skilled nurse who, based
on significant experiential learning, possesses an intuitive
grasp of clinical situations. This nurse performs in the clini-
cal setting with certainty, fluidity, and flexibility. The expert
nurse operates from a deep understanding of the total situ-
ation, which allows for rapid identification and response
to individual patient situations. Not all nurses will become
experts, and there is no time frame in which a nurse gen-
erally reaches this level of skilled performance.
10
Purpose of Review
A number of manuscripts have been published detailing
the experiences of new GNs and a variety of innovative
training methods that have demonstrated the potential
for improving GN role transition and work place satisfac-
tion during the first 6 to 18 months of employment.
11
The
purpose of this literature review is to examine and interpret
what is known about the GN role transition from novice
to competent practitioner in the acute care setting. Addi-
tionally, implications for nursing education practice in
the postlicensure setting will be explored.
Methods
Initially, this review was intended to be written as a synthe-
sis of the literature published regarding the lived experience
of new GNs in the emergency setting. However, the author
was unable to locate any published studies that specifi-
cally address the transition from novice to competent in
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436 JOURNAL OF EMERGENCY NURSING 34:5 October 2008
emergency nursing practice. Therefore, the literature review
was expanded to include all publications that specifically focus
on the GN experience, new graduate training program effec-
tiveness, and innovative approaches to facilitating the tran-
sition from new graduate to competent nurse.
The literature review for this article was conducted uti-
lizing a systematic review of the literature relating to post-
licensure clinical education and the lived experiences of the
GN. The literature review was conducted between March
and June 2007 using the following publication databases:
Medline, CINAHL, SCOPUS, and ProQuest Disserta-
tion Database. The period used for this literature review
included 1980 to 2007; however, publications selected
for review were limited to the period ranging from 1995
to 2007. The following are key search terms included in
this literature review: graduate nurse combined with educa-
tion, novice, advanced beginner, training, orientation, emer-
gency, experience, competency, qualitative, and transition.
The literature review initially identified 63 articles, of
which 21 were directly related to new graduate postlicen-
sure clinical education or the lived experiences of the GN,
and contributed to the body of knowledge regarding the
novice to competent transition in nursing practice. These
articles were read multiple times and classified in 2 ways.
First, the articles were categorized into 3 types: postlicen-
sure training program evaluation, GN experiences, and de-
scriptions of innovative educational programs. Second, the
articles were classified according to the study methodology
utilized, if applicable, resulting in 4 categories: qualitative
study, quasi-experimental study, descriptive study or ques-
tionnaire, and study design not applicable. Articles were
categorized as follows:
1. Postlicensure training program evaluation: N = 10
2. GN experiences: N = 7
3. Descriptions of innovative educational programs: N = 4
Study methodology for the papers reviewed included
the following:
1. Qualitative study: N = 6
2. Quasi-experimental study: N = 2
3. Descriptive survey or questionnaire: N = 10
4. Study design not applicable: N = 3
While this article cannot be classified as a meta-synthesis
of the research because nonresearch-related publications
are included in the review, the analysis method chosen for
identifying themes and interpreting the literature was Noblit
and Hares meta-ethnographic comparative review.
12
This
method was selected because it allows the reviewer to com-
pare and analyze text, creating new interpretations in the
process (p. 9).
12
Trends in the Literature
A comprehensive review of the literature revealed 6 major
themes. These themes can be collectively categorized into
2 groups: culture shock (barriers to success) and assimilation
(facilitators of success). Three of these themes relate di-
rectly to new graduate discomfort and dissatisfaction in the
acute care settings: work environment, stress/frustration,
and inadequate preparation for entry into practice. The re-
maining 3 themes have been identified as facilitators of
transition to competent clinical practice: mentoring, social
support, and orientation process.
CULTURE SHOCK
Newly graduated nurses enter the workforce enthusias-
tically, eager to learn, and hoping to assimilate into the
health care team.
2-4,6,7
Often, these neophyte nurses ex-
perience culture shock as they transition from the aca-
demic environment to the acute care setting. Most of
these nurses have never carried a full patient load or dealt
with the realities of professional nursing practice.
13
A re-
view of the literature suggests it is common for GNs to
feel inadequately prepared for what to expect when they
enter professional nursing practice, which results in culture
shock and challenges in assimilating into the institutional
culture.
2-7,13-15
The following themes represent barriers
to successful transition into practice and enculturation for
the GN.
Work environment
The work environment and norms of professional nursing
practice are not what many GNs expected when they enter
the workforce. Most nurses expressed frustration with their
work environment, including unsupportive workplace cul-
ture (particularly related to socialization and treatment by
peers), high nurse-to-patient ratios, and workplace condi-
tions that inhibit their ability to provide the level and type
of care that they have been taught is required of a good
nurse.
2-7,14,15
Because there is a divergence between the
nursing practice experienced in an academic clinical rota-
tion and institutional expectations experienced in the acute
care setting, new GNs are faced with having to learn how
to be a nurse and function within an unfamiliar, sometimes
unsupportive organizational culture, while being asked to
assume increasing levels of responsibility.
6
Stress and frustration
A common theme identified in all of the literature reviewed
emphasized the stress that GNs experience when transi-
tioning to professional nursing practice. While the new
work environment and feelings of inadequacy are elements
of the high level of stress experienced by novice and advanced
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October 2008 34:5 JOURNAL OF EMERGENCY NURSING 437
beginner nurses, other stressors have been identified in the
literature. Additional sources of stress include: (1) fear of
independent practice (worried about knowing what to do
and how to respond to patient needs); (2) dealing with
new situations
5-7,14
; (3) work schedule challenges, dissatis-
faction, or both,
2,5,14
; (4) unclear expectations
15
; and (5)
finances and student loans.
5
According to Casey et al,
5
who conducted a descrip-
tive survey study of 270 new GNs working in 6 acute
care facilities, 41% of GNs were dissatisfied with their
work schedules, 39% were unhappy with their salary,
and 40% believed that they had a lack of opportunities
for career development. These data are especially telling
given the reality that retention of GNs is historically poor
and increasingly costly.
5
Inadequate preparation
A review of the literature indicates that there are several
areas in which new GNs do not feel adequately prepared
for professional nursing practice. Overall, a feeling of a
lack of self-confidence was identified by nurses in nearly
all of the studies reviewed.
2-7,14,15
Specific areas that have
been identified from the research as areas in which GNs
felt unprepared include particular nursing procedures,
5-7
death and dying,
5-7
organizational skills and time manage-
ment,
2,3,5-7
inability to recognize subtle changes in patient
condition,
3,14
and communication with physicians and
patient families.
5-7
Specific procedures that GNs most
frequently cited as challenging include cardiopulmonary
arrest management, caring for patients with chest tubes,
and the insertion and maintenance intravenous, central,
and epidural lines.
5
ASSIMILATION
Facilitation of assimilation into the nursing practice cul-
ture is recognized by the literature as a major indicator
of novice and advanced beginner success in the clinical
setting.
2-7,13-17
Common themes in the literature related
to GN assimilation include mentoring, social support,
and orientation.
Mentoring
Mentoring by more experienced nurses, often occurring
through the use of clinical preceptors, is a consistent theme
in the literature. GNs indicate that the role of their pre-
ceptor and the quality of the mentor-mentee relationship
are defining factors in the development of self-confidence
and clinical competence.
2,5-7,13-19
To facilitate the syn-
thesis of findings in the literature, the terms mentor and
preceptor are used interchangeably in this article, although
it is important to note that these terms are not synon-
ymous. The following theme-based factors have been
identified as promoting GN assimilation in the acute care
practice milieu:
1. Preceptors should be carefully selected and trained to
ensure that they have the skills and desire to effectively
mentor novice and advanced beginner nurses.
2,5,10,15,16,20
2. GNs should be paired with mentors who can provide social
support, nurturing, and clinical guidance at an appropriate
skill and performance level.
5,6,10,15
3. GNs need adequate time with a consistent preceptor to
facilitate the development of a worthwhile relationship.
Specifically, mentoring should be long-term and ideally,
the preceptor and GN should work the same schedule to
provide continuity in the experiential learning process.
5,16,19
Social support
Social support in the clinical setting expands upon the
previous theme of mentoring to include the socialization
process experienced by the GN. In the context of the GN
experience, social support refers to encounters with peers,
the health care team, and administrative support. Recogni-
tion that the first 3 to 12 months in nursing practice fre-
quently is the most stressful and challenging time in
a nurses career includes creating a caring and supportive
environment that allows the GN to successfully acclimate
to the acute care culture. Specific social support interven-
tions that have been acknowledged as facilitators of success
include the following:
1. Providing education for practicing nurses about culture
shock and the experiential learning needs of nurse gradu-
ates upon entry into practice. This preparation of staff
facilitates the enculturation of new graduates on the nurs-
ing unit.
5,10,16,19,21
2. Providing formal and informal opportunities for socializa-
tion into the professional role.
16,17,21,22
3. Managers and educators must establish clear expectations
for the GN and preceptor while accounting for and provid-
ing support in the management of scheduling adjustments
(from the academic to health care setting), intensive learn-
ing, and professional growth.
16,20
Orientation process
The lack of congruence between hospital needs and the
needs of GNs has resulted in reported median turnover
rates for GNs during their first year of employment that
range from 35% to 60%.
5
To improve recruitment and
retention of GNs, many hospitals are initiating innovative
orientation and training programs intended to facilitate the
transition among GNs from novice to competent during
their first 12 to 18 months of employment.
11
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438 JOURNAL OF EMERGENCY NURSING 34:5 October 2008
A number of studies have been conducted to evaluate the
impact that nurse internships, residency programs, and en-
hanced orientation programs have on the GN transition from
student to competent nurse.
19,22-25
The current research
in this area indicates that the GNs require an orientation
process that is based on their individual needs assessment.
24,26
Further, there is evidence that nurse residency programs have
a positive return on investment by decreasing GN turnover,
increasing job satisfaction, and effectively producing compe-
tent and confident nurses.
16,18,22,24,26
Although there is no
template for the amount of orientation that an individual
nurse requires to transition to competent practitioner, the
literature suggests that a minimum of 6 months to 1 year
of combined training and mentoring is required for GNs
to feel confident in their ability to provide competent nurs-
ing care.
5,16,19,21,25-27
Implications for Emergency Nursing Education
There are several implications for ED managers and clinical
nurse educators that can be extrapolated from the litera-
ture. First, the impact that preceptors and mentors have
on the GN transition in the acute care setting is profound.
The importance of a detailed selection and preparation pro-
cess for preceptors to ensure that they have the skills and
desire to effectively mentor novice and advanced beginner
nurses cannot be minimized.
Second, emergency nurses and nurse managers in the
acute care setting need education about experiential learn-
ing and the lived experiences of GNs so they can provide
social support and assist in assimilation. Nurse managers
play an important role in the successful development of
novice nurses and can address the known stressors and
frustrations that may be experienced during entry into
practice. Further, although nurse residency programs re-
quire significant resource investment, the literature clearly
demonstrates that the return on investment makes these
programs an important part of addressing the educational
and socialization needs of GNs while attending to the re-
cruitment and retention issues faced by U.S. hospitals.
Finally, opportunities exist for improved collaboration
between academic and hospital settings. Innovations such
as the implementation of summer extern programs and
enhanced clinical experiences can be instrumental in GN
acclimation to the acute care setting.
13
Joint partnerships
between schools of nursing and clinical practice settings
can facilitate the development of educational programs
that better support the development of competency in
emergency nursing practice by identifying gaps in experi-
ence and preparation.
26
Additionally, these partnerships
provide a forum to discuss the content and breadth of
education provided at both the prelicensure and postlicen-
sure level.
Conclusion
Nurse educators struggle on a daily basis to find a bal-
ance between addressing the need to rapidly integrate
newly graduated nurses into the acute care practice milieu
while ensuring that these novice nurses are appropriately
supported during the transition to postlicensure indepen-
dent nursing practice. This review of the literature provides
a summary of how the transition along the novice to expert
continuum can be facilitated utilizing existing theory, prac-
tice, and research examples.
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