International Journal of Nursing Practice 2013; 19: RESEARCH PAPER. Accepted for publication February 2012

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1 bs_bs_banner International Journal of Nursing Practice 2013; 19: RESEARCH PAPER 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 Elizabeth Watt BAppScie (Adv. N), MNS, RN, RM, FACN Head, Clinical School of Austin Health, School of Nursing and Midwifery, La Trobe University, Heidelberg, Victoria, Australia Elizabeth Pascoe BSc (Hons). DipEd, MSc., RN Lecturer, Clinical School of Austin Health, School of Nursing and Midwifery, La Trobe University, Heidelberg, Victoria, Australia Accepted for publication February 2012 Watt E, Pascoe E. International Journal of Nursing Practice 2013; 19: 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 The nursing literature continues to give ongoing attention to university-educated nurses preparedness for practice in the first year following graduation. This interpretive descriptive study explored the impact of a university-based clinical school of nursing experience on graduate nurses perceptions of their preparedness for practice. Ten registered nurses who undertook their graduate year programme in the same hospital where they attended the university-based clinical school of nursing were interviewed. The interviews were audio-recorded, transcribed verbatim, and analysed to reveal themes and categories. Thematic data analysis revealed three themes: being situated in a clinical school within a hospital, the university away from the university and engagement with practice. The outcome of the experience of being situated in a university-based clinical school of nursing contributed to the participants sense of being prepared for practice as a graduate nurse. Key words: graduate nurse, nursing education, preparedness for practice, qualitative research. INTRODUCTION Since the transition from hospital-based education to universities in the 1980s, considerable attention continues to be given to university-educated nurses preparedness for practice. 1 3 The transition from a familiar educational Correspondence: Elizabeth Watt, Clinical School of Austin Health, School of Nursing and Midwifery, La Trobe University, Level 4, Austin Tower, PO Box 5555, Heidelberg, Vic. 3084, Australia. e.watt@latrobe.edu.au doi: /ijn environment into the unfamiliar workplace setting, where the expectation is to quickly perform as a competent registered nurse, is resulting in the newly qualified graduate nurse reporting stress, high anxiety, role adjustment issues 1,2,4 6 and feeling unprepared for the realities of the clinical setting. 3,5,7,8 Although the need to be prepared for practice also known as readiness for practice, practice readiness, fitness for practice and job readiness 3,9,10 has been widely discussed in the professional literature for a number of years, there continues to be a lack of common

2 24 E Watt and E Pascoe agreement between decision makers (educators and hospital managers) and clinical nurses over what constitutes new graduate nurses preparedness for practice. 10 Moreover, there is ongoing discussion in the literature about the contributing factors to a perceived lack of preparedness of new graduates, and how the education and practice sectors can more adequately prepare new graduates. 2 7,10 14 This paper reports on an interpretive descriptive study, which aimed to explore graduate nurses perceptions of their preparedness for practice after undertaking the final year of their bachelor of nursing degree in a universitybased clinical school of nursing. It is anticipated that the results of this study will inform future development within the clinical school programme, and add to existing knowledge on how nursing education programmes can enhance graduates preparedness for practice. The clinical school of nursing During a major curriculum reform, the School of Nursing and Midwifery at an Australian university established several clinical schools of nursing, with a key aim of improving their graduates preparedness for practice. The clinical schools are located within large metropolitan acute care hospitals in Melbourne, Australia. Several academic staff from the university are permanently situated within a multidisciplinary education precinct. Their role includes the development and coordination of the undergraduate theoretical and clinical programme. The majority of the clinical and theoretical programme in the final year of the bachelor of nursing degree is conducted within the clinical school of nursing, and there is close articulation between practice and theory throughout the year. An important component of the clinical school has been the development of a bipartisan relationship between the university and the hospital. An outcome of the relationship has been the development of a clinical experience model, whereby academic staff work closely with clinicians in the day-to-day conduct of the students clinical placements, and in the application of theory to practice. Clinical experts in the hospital are invited to deliver lectures, associated workshops, and skills development sessions. Factors contributing to lack of preparedness for graduate practice Ongoing debate about the issue of preparedness for graduate practice continues within the nursing literature, with a multiplicity of factors seen as influencing the process. Several of the factors associated with preparedness for graduate practice are relevant to this study: the consequences of the gap between educational institutions and the practice setting, 2 4,6,10 13 the quality of undergraduate clinical placements, 3,7,9,14,15 the need for students to feel a sense of belonging within the clinical environment 15,16 and the lack of socialization to the real world of nursing. 2,4 Universities have been criticized for being too distant from the practice setting and presenting students with the ideal rather than the reality of nursing practice. 3,10 A number of authors argue that the dissonance between the expectations of graduate performance by the service and educational sectors has created an education-practice gap between the sectors. 2,3,11,12 A lack of communication 2 and shared responsibility 4,6,12,13 between clinical and academic staff are also identified as key compounding factors to the perceived education practice gap. Promotion of closer links between educational institutions and health-care agencies is identified as an important way of addressing this problem. 2,10 The nature and quality of students clinical learning experience have been criticized. 3,9,14,15 In the quest to academically develop a problem-solving, decision-making and critically reflective nurse, the opportunity to apply these skills in a clinical setting has been reduced, with the student often functioning as an observer rather than an active participant in managing patient care. As a result, the new graduate nurse perceives the acute care setting as an unfamiliar place. 7 Olson 7 makes the pertinent point that whereas most graduates undertake their first year of practice in an acute care environment, in reality they have had little acute care experience in their undergraduate programme. Moreover, the nature and quality of clinical experience are more than just being familiar with the clinical environment. The need to feel a sense of belonging also impacts on the newly qualified nurses capacity to be prepared for the rigours of clinical practice. 15,16 The sense of belongingness, 15,16 whereby individuals feel secure, accepted, respected and connected, enhances clinical learning 15,16 and preparedness for practice. 9 A lack of socialization to the organizational culture, for example, knowledge and experience of organizational norms and values, contributes to the new graduate nurse s sense of lack of preparedness for practice. 2,4 In the study by Newton & McKenna, 4... learning to know where they fit in, whom to ask, when not to ask (p. 1235), were important factors associated with being prepared for

3 Preparedness for practice 25 graduate practice. Within the workplace, new graduates are often expected to perform at levels consistent with experienced employees when they are still learning the procedures, policies and idiosyncrasies of the employing organization. 2 These factors have the potential to distract the new graduate from the important job of needing to become a confident and competent professional nurse, thus adding to the sense of dissonance, stress and anxiety. 7,17,18 METHODS The study used interpretive descriptive methodology. 19,20 The location was a large metropolitan acute care public hospital in Melbourne, Australia, where the clinical school of nursing is situated. The participants comprised a purposeful sample of first-year graduates who attended the university-based clinical school of nursing in the final year of the Bachelor of Nursing programme. Ethics approval to conduct the study was obtained from the University and hospital Human Ethics Committees. An invitation outlining the aim and scope of the study was sent to potential participants. Written informed consent was obtained prior to the interview. Ten participants (nine females and one male) completed an interview. All participants were in the final months of their first year as a graduate nurse. To maintain confidentiality and anonymity, each participant was given a pseudonym, and no identifying information was transcribed from the interviews. Each participant was interviewed using a semistructured format. Interview guidelines were developed to ensure congruency between the two interviewers. The interview focused on the graduates experiences in the final year undergraduate university-based clinical school programme, as well as their perception of the adequacy of the clinical school experience in preparing them for practice as a registered nurse. The questions were open ended in structure to encourage rich, descriptive and unforced responses. 20,21 For example, Reflecting on your final year at the clinical school, can you identify what has helped you feel prepared for practice as a graduate nurse? The interviews were audio-recorded, with the permission of the participant to ensure data reliability. 21 Each interview lasted between 30 and 45 min. The data analysis was undertaken in three phases. Phase one involved analysis in action. The interviewers were carefully listened to for emerging themes, which informed the depth of questioning within the interview and subsequent interviews. 20 In phase two, the audiorecorded interviews were transcribed verbatim, read and re-read so that the researchers became immersed in the data prior to identifying linkages and themes. 19 Phase three involved the use of the computer software programme NVivo 7 (QSR International, Doncaster, Victoria, Australia) to identify themes and sub-themes within the data. 20 The data analysis generated seven sub-themes. Following further analysis, three major themes emerged. FINDINGS Three major themes emerged from the data analysis: being situated in a clinical school within the hospital, the university away from the university and engagement with practice. The overlapping of the three themes facilitated the participants perception of a sense of preparedness for graduate practice (see Fig. 1). Theme 1: being situated in a clinical school within the hospital This theme describes the participants perception of the value of being situated in a hospital where they had the opportunity to immerse themselves in the daily machinations of the organization. The three sub-themes are environment, administration and organizational culture. Environment Being familiar with the environment meant that as new graduates, the participants were quickly able to focus on the central issue of learning how to care for patients because everything was familiar. For example, a participant commented:... I knew where things were so all that feeling of unknown stuff was only about the nursing as opposed to the organization, so that was a big benefit. Another said:... it sounds weird, but you d think being at a hospital [in the clinical school] that it would be a bit more fast paced, and a bit more anxiety driven being here; but I found it was almost relaxing, it got you used to being here, after being for a whole year it helped, you knew where everything was, you knew the surroundings. Administration As an undergraduate student, knowing how and where to access clinical resources and information such as

4 26 E Watt and E Pascoe The university away from the university Engagement with practice Being situated in a clinical school within the hospital Facilitates Preparedness for practice Figure 1. Themes and outcome. equipment, charts and protocols, enabled the participants to feel they were a functioning member of the ward team. They expressed a capacity to hit-the-floor-running. For example: I knew where to go for resources, I knew where to find protocols, I knew how the system worked already... and I think that made all the difference in starting out. You know the charts, paperwork; everything was familiar.... If I hadn t been here, then I might have been wasting a lot of time asking questions about some of those things like where do I find a protocol, or where do I find this particular stock, or even just how to fill in a chart and that sort of thing. The graduates ability to feel that they were ready to hit-the-floor-running was an important factor in reducing the fear of making mistakes or not doing a good job. 2 As Fox et al. 22 point out, an understanding of the way the organization works, knowing the system (p. 198), also makes a positive difference. Organizational culture In addition to the benefit of knowing the environment and administrative processes, being situated in a universitybased clinical school of nursing in the final undergraduate year also enabled the participants to establish themselves within the ward and organizational culture: Just physically being here changes so much; the culture of [the] organization, model of care, getting to know people, good contact with academic staff; [I] felt part of the organization, seeing the same staff members. They know you and trust you... Having an understanding of the way the organization worked before commencing their graduate year made a positive difference to the participants confidence levels. Being situated in a clinical school provided these graduates with the opportunity to understand the rules and dominant hierarchy of the organization, and their place within the nursing culture. 4,22 Theme 2: the university away from the university This theme describes the participants perception of the value of being in a university-based clinical school of nursing. This was a distinct and different experience from previous years of the Bachelor of Nursing programme, where classes were conducted at the university separate from clinical placements. The two sub-themes are: the

5 Preparedness for practice 27 physical co-location of the classroom and practice environment, and bringing the real world of practice directly into the classroom. Physical co-location of the classroom and practice environment Many participants commented that having classes and clinical placements in the same location minimized the gap between the university and practice experience. As one participant commented:... it was easy just to drop in if we had any questions and it was good being able to combine the theoretical and the practical together in one physical location and having the library there and the resources of the teaching staff close by as well. Participants also referred to the ease of getting information for assignments and study. Within the clinical school, students have access to the hospital intranet, which provides clinical information and policy documents, the hospital library, and the university library via the Internet. Significant effort has been put into library liaison between the hospital and university. Students can request books for loan from the university library through an online form: We have a library here, which has just as good books and journals as [the University] and so it s another uni away from uni. The co-location of university services within the clinical environment assisted the participants to manage their time more productively: Just the physicality of it really. It s so handy. And to have clinical here and then pop down to the office and ask a few questions regarding the assignments and handing them in; you don t have to jump from one place to the other... Further, the co-location of the university-based clinical school within the hospital also contributed to the participants perception of the future workplace: You get a better picture of your overall environment that you [are going to] be working in, and it gives you more of a realistic expectation. Knowledge of the reality of the practice environment is an important factor for practice readiness, and eases the stress experienced by new graduates. 2 The participants perceived their educational experience to be realistic, thus assisting them to understand the reality of nursing work: I think it was a big reality to change from uni all the time where you do lectures, but to be here was a big change... I saw things in a different light, I guess... like the reality check, this is what I am going to be doing, these are the people I am going to be working with what are they doing and how they are coping?... The participants perceived that the integration of university services into the clinical school enabled them to engage in learning without wasting time travelling to the university to contact academic staff and to access university services. They commented that clinical experiences were enhanced by having academic staff located within the hospital as a first point of contact: The support is good as well. Obviously we were several floors up or down from tutors who would come and see us and it was easy to drop in if we had any questions. Bringing the real world of practice directly into the classroom An educational advantage of having a clinical school located within a hospital is the capacity to bring the clinical environment into classroom activities. As one participant commented:... you do talk about it in your lectures and you do physically go up to the wards and see those things. That s a big deal to see it in the practice environment which is also the uni. Bringing the real world of practice directly into the classroom assisted the participants to apply knowledge in practice. 4,7,13,23... I was very excited to be at the hospital because at [the university], I know we ve got a lab there, but it doesn t really feel the same, [it] feels like it s all made up, but when you are actually in the hospital it feels real. For the participants, being situated in the clinical school enhanced the reality of their learning. This was a powerful motivator to engage in practice and work hard to gain and apply knowledge and skills to practice. Theme 3: engagement with practice This theme describes the participants perceptions of how they engaged with clinical practice in a way that was

6 28 E Watt and E Pascoe different from their clinical experience in previous years of the course. For the participants, being situated in a university-based clinical school minimized the conceptual, philosophical and practical distance between theory and practice commonly experienced by undergraduate students, 2 thus facilitating engagement with practice. The capacity to engage with practice enabled them to have insight into what it is to be a real nurse and not just a mere visitor in the clinical setting, with a clear understanding of the expectations of being a registered nurse. For example: Because you are here the whole year it gives you realistic expectations about the future. [I] felt less anxious being here and that helped [me] to learn quicker. [I] felt like a real nurse rather than just a student. Being situated in a clinical school:... gets you into the whole mindset of becoming a nurse and makes you enthusiastic, so that s a positive. I know that with some unis, they don t really see the hospital until they land on the doorstep. Because the participants felt able to engage with practice, they expressed a realistic rather than idealized conceptualization of nursing, 24...realizing that I had to take responsibility. And because they were able to engage with clinical practice in a realistic and meaningful way, this didn t deter them from pursuing a career in nursing, [it]... confirmed that nursing was what I wanted to do. DISCUSSION Existing literature has examined preparedness for practice from two broad perspectives: the constituents of preparedness for practice, and the best way to facilitate it. This study addressed the latter issue how the experience of being in a university-based clinical school of nursing facilitates graduate preparedness for practice. The findings from this descriptive explorative study indicate that the structure and processes associated with the clinical school model provide a foundation for addressing the diversity of issues that contribute to a lack of graduate preparedness for practice. The most reported factor contributing to graduate preparedness for practice is the quality of undergraduate clinical experiences. Within the clinical school model, students are given quality experiences that are perceived as meaningful to them. They are rostered (across the week) to work alongside a designated preceptor (registered nurse) in the clinical setting over the semester. The students participate in all activities associated with the ward so that they can develop familiarity with the physical environment and organizational culture essentially becoming part of the ward team. This arrangement positively influenced the participants sense of belonging, enabling them to redirect their attention and energy on learning rather than trying to fit in to the physical environment and organizational culture. 15,16 Moreover, the close relationship between clinicians and academic staff fostered a climate where students, rather than being perceived as an additional burden on clinical staff, are considered important members of the team. Academic staff actively prepare and support the preceptors, and facilitate student learning in the clinical environment. Academic staff meet with each student on a daily basis and discussions focus on clinical reasoning, prioritizing patient care and time management. Students also have an opportunity to discuss their clinical expectations and progress. Preceptors are invited to review the student s performance and give feedback. This model of support has enabled the development of a trusting relationship, and shared understanding about standards, expectations and accountability about student performance between the student, clinical and academic staff. Thus, clinical learning is seen by all parties as a collaborative endeavour. 3 Other factors not widely reported in the literature, but nevertheless identified as influencing graduate preparedness for practice, are associated with communication 2 and shared responsibility 4,6,12 14 between the practice and education sectors. The physical location of the universitybased clinical school within the hospital facilitated the development of a close connection between the education and practice setting, and fostered close working relationships. Rather than the hospital being seen by the university solely as a provider of clinical learning experiences, the clinical school model has enabled a multi-layered symbiotic relationship to exist between the two organizations. The themes that emerged from the data analysis, being situated within a clinical school within the hospital and the university away from the university are a direct outcome of the symbiotic relationship. An educational advantage of locating the universitybased clinical school within a hospital is the capacity to bring the real world of practice directly into the classroom. For example, the use of real patient situations and

7 Preparedness for practice 29 hospital documentation in problem-based learning sessions diminished the boundaries between the classroom and the hospital. Skills learning sessions are enhanced with real patient contact through ward rounds relevant to the particular skill. In the ward rounds, academic staff take a small group of students to visit a patient, examine the skill in context, the assessment and documentation required and, where possible, gain a sense of the patient experience. This offered the student an opportunity to be socialized into the real world of nursing, 2,4 thus reducing the perceived gap between theory and practice. Despite all the aforementioned positive outcomes for graduates in being located in a university-based clinical school during the final year of their undergraduate nursing programme, the clinical school model appears to have limited impact on the participants capacity to be prepared for the realities of shift work, a factor that impacts on graduate preparedness for practice. 6,17 Although the participants were aware of the reality of having to do shift work, their experience within the clinical school did not minimize the impact of shift work on their lives. Arguably, however, because a number of the factors associated with lack of preparedness for practice are minimized by being situated in a university-based clinical school, it might be as graduates they are better prepared to deal with the realities of shift work positively and constructively. The main limitations of this study relate to retrospectivity, the small sample size from a single venue and the single mode of data collection all of which limited the level of analysis. 25 As the participants had the opportunity to reflect on their final year in the university-based clinical school in its entirety, this could have resulted in enhanced feelings of satisfaction. 26 In future research, it would be valuable to undertake a comparative study to investigate if the same outcomes are generated for graduates who chose to undertake their graduate year in another hospital. CONCLUSION The participants narratives supported the discussion in the literature on how best to facilitate preparedness for practice, and also confirmed the findings from the literature, which identify the factors impacting on the ability of the new graduate nurse to be prepared for practice. 2 7,10 14 The findings of this study provide insight into the effect of being situated in a university-based clinical school of nursing on the participants preparedness for practice. The outcome of the clinical school experience was that the participants felt prepared for practice as new graduates. Their narratives revealed that the clinical school experience provided them with a physical and educational bridge between university life and clinical expectations: It [the clinical school] allowed me to stick my head in the door and get me used to the place. A university-based clinical school of nursing has the potential to offer a model for enhancing new graduate nurses preparedness for practice. ACKNOWLEDGEMENTS Special thanks go to all the nurses who took part in the study and Ms Leanne Pausic for her assistance in transcribing the interviews. REFERENCES 1 Chang E, Hancock K. Role stress and role ambiguity in new nursing graduates in Australia. Nursing and Health Sciences 2003; 5: Romyn DM, Linton N, Giblin C, Hendrickson B, Limacher L, Murray C. Successful transition of the new graduate nurse. International Journal of Nursing Education Scholarship 2009; 6: Wolff AC, Pesut B, Regan S. New graduate nurse practice readiness: Perspectives on the context of shaping our understanding and expectations. Nurse Education Today 2010; 30: Newton JM, McKenna L. The transitional journey through the graduate year: A focus group study. International Journal of Nursing Studies 2007; 44: Duchscher JE. Transition shock: The initial stage of role adaptation for newly graduated registered nurses. Journal of Advanced Nursing 2009; 65: Casey K, Fink R, Krugman M, Propst J. The graduate nurse experience. Journal of Nursing Administration 2004; 34: Olson ME. The Millennials : First year in practice. Nursing Outlook 2009; 57: Winter-Collins A, McDaniel AM. Sense of belonging and new graduate job satisfaction. Journal for Nurses in Staff Development 2000; 16: Nash R, Lemcke P, Sacre S. Enhacing transition: An enhanced model of clinical placements for final year nursing students. Nurse Education Today 2009; 29: Wolff AC, Regan S, Pesut B, Black J. Ready for what? An exploration of the meaning of new graduate nurses readiness for practice. International Journal of Nursing Education Scholarship 2010; 7: Ellerton M, Gregor F. A study of transition: The new nurse graduate at three months. Journal of Continuing Education in Nursing 2003; 34: 103.

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