28 Nurse Leader November/December 2003

Almost 30 years ago, Marlene Kramer

1
published the
first major work on the reality shock experienced by stu-
dent nurses when they entered the workplace. Some
progress has been made, but we still have a long way to
go. A recently completed project, in which 35 new gradu-
ates across the United States were followed from the end
of their senior year in school through their first 9 months
of practice, offers insight into the work world as seen by
new graduates. From their feedback emerge clear strate-
gies that can be implemented to nurture and support new
graduates in their transition to registered nurses.
NEW GRADUATES ARE NOT ALL ALIKE
This particular group of graduates demonstrates that
the typical graduating classes previously seen are no more.
The participant group for the project was composed of 31
women and 4 men who ranged in age from 21 to 60 with
an average age of 29. Twenty-one of them were completing
bachelors degrees, and 14 were completing associate
degrees.
For 10 participants, nursing is not their first career. One
was retired from 20 years in the military, and one had been
an accountant for 15 years. Several had spent years being a
wife and mother and were just responding to their long-
held desire to become a nurse. Several participants had
moved to nursing from other health care careers (licensed
vocational nurse, emergency medical technician, or certi-
fied nursing assistant). This diversity is typical of current
new graduates and speaks to the need to better individual-
ize how we recruit and orient new nurses. In addition, it
demonstrates that many new graduates bring a wealth of
knowledge in diverse areas and may be ideal for some of
the new blended roles evolving in health care.
FINDING THE FIRST JOB
Part-time work during school had a major impact on
looking for the first job. With only minor exceptions, stu-
dents who worked part time during school and were made
to feel that a position would be waiting for them when they
graduated rarely looked at other job options. Externships
Beth Ulrich, EdD, RN, CHE
Successful Strategies for
New Graduates
The current nursing shortage has been an enormous challenge for all nurse leaders. The
latest news concerning increased interest in nursing as a career and enrollment in nursing
schools holds promise, but only if we can recruit and retain new graduate nurses.
November/December 2003 Nurse Leader 29
and programs that allow students to work during their
school years and that bond the student to the organization
can be key strategies in recruiting new graduates.
For new graduates who have not worked part time in a
health facility during school, the interview process is their
first chance to learn about an organization they are consid-
ering for employment. From the notes kept by the partici-
pants in this project, it is clear that many new graduate
interview experiences could be improved. New graduates
like interviews conducted in comfortable, informal settings
and like being given scenarios so they can demonstrate
their knowledge. Interviewers who are prepared make a
positive impression, as do those who understand that new
graduates want to know how nursing is organized, what
staffing is really like, what will be expected of them as new
graduates, and what the organization is prepared to do to
help them be successful. Full explanations of all compensa-
tion and benefits are a must. Extensive compensation and
benefit options increase the likelihood of hiring new grad-
uates as their differences in needs and wants result in dif-
ferent priorities.
Tours of units and interviews by staff nurses are appreci-
ated, but they need to be structured to be successful.
When touring a facility, new graduates look for signs of
teamwork and organization. What they often see, however,
is a lack of staff, perceived chaos and instability, organiza-
tions that feel impersonal, and backbiting.
Unfortunately, not all interviews go well. Given the
shortage of nurses, it was surprising to hear about what
some of the participants experienced. Interviewers,
whether recruiters or nurse managers, frequently were late
for scheduled interviews, gave the impression that the
interview was an inconvenience, and often did not follow
up. New graduates often felt that the interviewers acted
like they were doing them a favor to interview them and
expected the new graduates to automatically take the job if
it were offered. They also commented frequently on what
appeared to be a lack of communication between their var-
ious interviewers. It is important to define the roles of
everyone who will interact with the potential new employ-
ee during the interview process. Interviewers need to be
educated on how to conduct interviews, and communica-
tion must occur among all interviewers and recruiters. The
new graduate interviewee must be told the details of the
interview process and results.
Honesty and integrity in interviews also were an issue
for several new graduates. In several clear instances, par-
ticipants were promised something when they were inter-
viewed and hired, only to find the promises broken when
they arrived to begin work. In one case, a new graduate
was told that the person who had told her she would
receive a certain hiring bonus did not have the authority
to commit the facility to that amount of money and the
hiring bonus actually was much less. Another graduate
was hired for a postpartum unit only to be assigned to a
medical-surgical unit. The specifics of job offers must be
in writing.
ORIENTATION, INTERNSHIPS, PRECEPTORS,
AND MENTORS
New graduates come out of school after studying for
what seems to them like a very long time, and they want
to do what they studied. What they do not want to do is
sit in classrooms all day. The most frequent word used to
describe orientation was boring. The clear consensus
of the new graduates in this project was that, though
they felt the need for some orientation, they wanted to
care for patients and were very frustrated when their
orientations did not allow them at least some direct
care experience.
New graduates who participated in internship programs
really enjoyed them and seemed to get their confidence
faster than those who did not. They liked being with other
new graduates, seeing how other departments work, shad-
owing experienced nurses, and getting more experience
themselves before they had to practice independently. As
with orientation, new graduates dislike internship time
spent away from their units in classrooms.
Preceptors clearly made a big difference in how well the
new graduates developed confidence in their abilities in
the first year. Graduates who had preceptors that were
consistent seemed to gain confidence more quickly and
feel better about themselves as nurses. Too often, howev-
er, preceptors were pulled to other assignments, and new
graduates were left either without a preceptor or having to
switch to a new one. Each time they changed preceptors it
felt like starting over.
Some organizations, recognizing that the preceptor
time is limited to weeks or months because they must
move on to the next set of new graduates, have instituted
programs that provide new graduates with mentors after
the preceptor period is over. The mentors role is struc-
tured more as a big brother or sister rather than the pre-
ceptor/teacher role and provides a security blanket for the
new nurse.
Nurse educators and leaders spend large amounts of
time planning orientation and internships and working
with preceptors to create the best possible initial environ-
ment for new graduates. The question becomes how to
accomplish the mandatory orientation content and ensure
necessary competencies without tamping out the excite-
ment and wonder of a new graduate. We need to find ways
to encourage and continue the enthusiasm new graduates
bring to organizations.
TRANSITIONS
Though organizations are concentrating on a smooth
transition, many young new graduates also are experiencing
life transitions. This may be the first time they have held a
full-time job, lived on their own, or had to work 12-hour
shifts. Some young new graduates are getting married or
moving to a different state. It is helpful to appreciate that
becoming a registered nurse is only one of the transitions
being experienced. Young graduates are very appreciative
when someone from the organization can spend time with
them one-on-one discussing life transitions and offering
assistance, even if just an empathetic ear.
The first year of practice as a professional nurse is filled
with ups and downs. New graduates come into organiza-
tions both excited and scared. They are ready to conquer
the world but also are scared because they understand that
patients could be hurt if they dont do their job well.
The first thing new graduates often realize is what they
dont know. They quickly understand that more clinical
experience as a student would have been worthwhile, and
they begin to appreciate why some things they thought
unnecessary to learn, like critical thinking, are so very
important. The amount of paperwork surprises them.
They learn that concise charting is a skill and how radically
different it is than even the extensive charting they were
required to do as students. They may be perplexed by
roles of various health care professionals and what they
can and should delegate and to whom. Communication
with doctors frequently is intimidating. During their clini-
cal rotations, most students do not communicate directly
with doctors and, as a consequence, come to the regis-
tered nurse role ill-prepared. They expect collegial com-
munication from physicians but rarely get it.
The other main thing that new nurses quickly become
aware of is the entire span of the role and how big a
responsibility it is to be in the profession. As students, they
see only snippets of what nurses do, a few threads of the
intricate tapestry of nursing. Also, as students, they always
have someone to back them upsomeone who has the
answer even when they dont. As they move into practice
as a registered nurse, they realize that they are often
looked to as the expert. In school, many tests are multiple
choice, and new graduates understand that, in the real
world they have moved into, situations are rarely as black
and white as their exams, and that there is no finite list of
options offered for each situations; they often have only a
short amount of time and what they know as their
resources when critical decisions are required. Internships
and preceptors are a big help in easing this aspect of the
transition.
Clarifying the expectations and realities of the regis-
tered nurse role while they are still students, or at least in
the very early days as a new graduate, could minimize sur-
prises and role incongruities and make the transition much
easier.
HIGHS AND LOWS
New graduates experience many highs and lows in their
first months of practice. Highlights include such things as
patients telling them how much they appreciate them,
getting an intravenous line started on the first try, getting
all their meds passed on time, patients saying thank you,
and hugs from appreciative family members. Lows range
from being yelled at by a doctor to making a medication
error to having a patient die. Though some of the highs
and lows are what even experienced nurses would view as
significant events, many instances are things that experi-
enced nurses would see as minor. In working with new
graduates, it is important to understand and respond to
them based on how they feel about these eventsto cele-
brate all highs and adequately address all lows.
CONCLUSION
Preventing or minimizing reality shock and successfully
moving new graduates through the transition into the reg-
istered nurse role can be achieved. Based on knowledge
gleaned from this project, key strategies include:
Developing opportunities for student work experiences
to bond students to the organization well before gradu-
ation
Respecting the diversity of new graduates with compen-
sation and benefits options and highly individualized
orientation
Developing interview processes in which interviewer
roles are clearly defined, all interviewers are trained as
such, time and interviewees questions are respected,
the process is described in detail so interviewees know
what to expect, interviewers communicate with each
other, follow-up is ensured, and job offers (with com-
plete details) are made in writing
Developing orientations and internships that provide
necessary information, ensure competencies, are tai-
lored, emphasize direct care and allow many direct care
activities, and encourage and maintain new graduates
enthusiasm
Clearly defining role expectations at various stages of
the transition to an RN
Providing new graduates with consistent preceptors
Recognizing all the transitions the new graduates are
experiencing
Educating all staff on how to nurture and support new
graduates
As one new graduate said, The most wonderful feeling
is knowing that there are people around you who support
you and are there to help you. I have lots of encourage-
ment and nurses tell me that I am doing well, even when I
had a bad day and feel that I didnt get everything done.
The more encouragement I get, the better I can function
as a nurse. The time and energy required to create envi-
ronments that nurture new graduates and provide encour-
agement and support are critical investments to successful-
ly recruit and retain new graduate nurses.
Reference
1. Kramer M. Reality shock: why nurses leave nursing. St. Louis: CV
Mosby; 1974.
Beth Ulrich, EdD, RN, CHE, is regional vice president and editor
for Nurseweek Publishing, Inc., and editor of Nephrology
Nursing Journal in Houston, Tex. She can be reached at
BethUlrich@aol.com.
Copyright 2003 by Mosby, Inc.
1067-991X/2003/$30.00 + 0
doi:10.1067/nrsl.2003.86
30 Nurse Leader November/December 2003