1 NEW GRADUATE NURSES’ EXPERIECNES WITH PRECEPTORS DURING A RESIDECNY PROGRAM A thesis presented by David E. Schultze to The School of Education In partial fulfillment of the requirements for the degree of Doctor of Education in the field of Education College of Professional Studies Northeastern University Boston, Massachusetts June 2017
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NEW GRADUATE NURSES’ EXPERIECNES WITH PRECEPTORS DURING A RESIDECNY PROGRAM
A thesis presented by
David E. Schultze
to
The School of Education
In partial fulfillment of the requirements for the degree of
Doctor of Education
in the field of
Education
College of Professional Studies
Northeastern University
Boston, Massachusetts
June 2017
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Abstract
Nurse turnover is a significant problem leading to nursing shortages in many hospitals.
This shortage will continue to grow, especially as the baby boomer generation starts to retire, if
hospitals do not implement changes to retain qualified nurses. Nurse turnover not only puts
patients at risk for substandard care, but also leads to increases health care-related costs as
organizations try to recoup the cost of training and orientating new nurses. Therefore, retention,
turnover, and quality of care are essential organizational drivers. One strategy targeting all of
these drivers is preceptorship, in which a preceptor facilitates the assimilation and amalgamation
of newly hired nurses into their role. The purpose of this study is to examine and evaluate the
lived experiences of recently graduated registered nurses’ interactions with preceptors during
their orientation. Identifying the traits and techniques used by highly effective preceptors will
assist in developing a more effective preceptor teaching model, potentially improving job
retention, quality of care, and reducing turnover. This study aims to accomplish this goal by
isolating their actions and behaviors through the verbal descriptions and perceptions of new
graduates. New graduates in this study raised themes of communication and trust, management
support, guidance and role modeling, technical skill development, and improving confidence.
The study’s evaluation of preceptors is intended to assist in restructuring the preceptor training
program at the research site. Establishing an educational and supportive program for preceptor
training can assist preceptors in their role and affect new graduate nurses’ job satisfaction and
retention. Both new graduate nurses and preceptors will benefit from the precepting process as
well as assist in a positive patient outcome.
Keywords: preceptor, new graduate nurse, preceptee, nurse residency program, nurse
retention, preceptor training, communication, critical thinking, technical competency
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Dedication and Acknowledgments
This dissertation is dedicated to my father, Dr. Ed Schultze, who at 75 years of age, proved one was never to old to go back to school. To my mother, Mary Ellen Schultze, a truly passionate and professional nurse who inspired me to become a nurse. To my dear friends Mary Kim, Bret, and Sydney who have been with me from the start, offering their support and guidance. Finally to Shane, who was there by my side offering encouragement and a shoulder to lean on.
I would like to express my gratitude to my advisor, Dr. James Griffin, for his guidance and support. His suggestions and feedback assisted me in taking an idea and developing it into this thesis. To my second reader, Dr. Sandy Nickel whose comments and recommendations assisted in fine-tuning this thesis. To Dr. Elaine Mohn-Brown, my third reader, whose positive encouragement and being there for me to talk to were instrumental in helping me complete this project. Thank you all.
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Table of Contents
Abstract……………………………………………………………………………………………2
Dedication and Acknowledgments………………………………………………………………..3
Table of Contents……………………………………………………………………………..…...4
List of Tables……………………………………………………………………………………...7
Chapter One: Introduction………………………………………………………………………...8
Organization of this thesis………………..……………………………………………….9
Statement of the problem………………………………………………………………...10
Issues new graduates face………………………………………………………..12
Significance of the problem…………………………………………………….………..14
Benefit of research……………………………………………………………………….16
Positionality statement……...….………………………………………………………...18
Research question………………………………………………………………………..21
Theoretical framework…………………………………………………………………...22
Benner’s model of novice to expert……………………………………………...23
Novice……………………………………………………………………24
Advanced beginner………………………………………………………25
Competent………………………………………………………………..25
Proficient…………………………………………………………...…….25
Expert…………………………………………………………………….26
Summary…………………………………………………………………………………27
Chapter Two: Literature Review………………………………………………………………...29
Aspects of the nursing role……..………………………………………………………..29
Mentorship……………………………………………………………………….30
Mentoring in health care……………………………………...………………….32
The nurse as preceptor…………………………………………………………...32
Workplace entry and turnover…………………………………………………………...35
New graduate’s entry into the workplace……………………………………......36
Graduate nurse turnover………………………………………………………….37
Issues new graduates face………………………………………………………………..39
Critical thinking………………………………………………………………….40
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Technical competency…………………………………………………………...42
Confidence improvement………………………………………………………...46
Socialization/communication improvement…………………………………..…47
Reality shock……………………………………………………………………..49
Burnout…………………………………………………………………………..51
Summary…………………………………………………………………………………54
Chapter Three: Research Design……………………...…………………………………………56
Research design………………………………………………………………………….56
Research tradition………………………………………………………………..57
The phenomenology of Van Manen……………………………..………58
Application to research…………………………………………………..60
The participants………………………………………………………..............................61
Recruitment and access………………………………………………………..…63
Data collection…………………………………………………………………………...64
Data storage……………………….……………………………………………..66
Data analysis……………………………………………………………………..66
Trustworthiness…………...……………………………………………………...69
Summary...……………………………………………………………………………….70
Chapter Four: Results and Findings……………………………………………………………...71
Emergent Themes.………………………………………………………………….........71
Theme one: communication and trust…………………………………..………..71
Theme two: manager support…………………………………………………….76
Theme three: developing technical skills………………………………………...79
Theme four: confidence improvement…………………………………………...82
Theme five: role model and socialization………………….…………………….85
Research limitations……………………………………………………………………...88
Summary…………………………………………………………………………………89
Chapter Five: Interpretations, Recommendations, and Conclusion……………...………………91
Interpretation of primary findings………………………………………………………..92
Communication and trust………………………………………………………...93
Manager support…………………………………………………………............95
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Development of technical skills………………………………………………….95
Confidence improvement………………..……………………………………….96
Role model and socialization…………………………………………………….98
Review of Themes in relation to Literature Review…………………………………......99
Critical thinking……………………………………………………………...…..99
Technical competency………………………………………………………….101
Confidence improvement……………………………………………………….102
Socialization and communication improvement………………………………..103
Reality shock and burnout……………………………………………………...104
Discussion………………………………………………………………………………105
Recommendations…………………………………………………………………..…..109
Recommendations for general practice…………………………………...…….112
Recommendations for future research………………………………………….114
Conclusions…………………………………………………………………………..…116
References………………………………………………………………………………………119
Appendix A: Northeastern University’s IRB Approval………………………………..……….162
Appendix B: Salem Health’s IRB Approval……………………………………………………163
Appendix C: Interview Guide…………………………………………………………………..164
Appendix D: Participant Demographics………………………………………………………..165
Appendix E: Excerpts of Field Notes From Participants’ Interviews.……...…………………..166
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List of Tables
Table 3.1 Demographic Make-up of Participants..........................................................................62
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Chapter One: Introduction
New nurses who have graduated from an accredited program often experience difficulty
developing a clinical foundation of skills as they transition from the role of student nurse to one
of a practicing registered nurse due to the state of fluctuation in today’s health care system
(Aiken & Clarke, 2003; Candela & Bowles, 2008; del Bueno, 2005; Orsolini-Hain & Malone,
2007; Ulrich et al., 2010). It is imperative new graduates develop and maintain a strong
foundation of both clinical and non-clinical skills from which to build upon. This not only
supports progressive professional development, and a safe and healthy work environment, but
assists in upholding the nursing tradition of trust and respect from patients, their families, and
the public in general. Recent literature on role transition in nursing encourages health care
organizations to develop programs to support the needs of new graduates, while facilitating
their continued development and strengthening their core nursing skills learned in school
(Casey, Fink, Krugman, & Propst, 2004; Duchscher, 2009; Duclos-Miller, 2011; Dyess &
Sherman, 2009; Fero, Witsberger, Wesmiller, Zullo, & Hoffman, 2008; Kovner et al., 2007;
Marshburn, Engelke, & Swanson, 2009; Roth & Johnson, 2011; Ulrich et al., 2010).
Even with research to guide health care organizations in the creation of supportive
programs, constantly reexamining the issues facing new graduate nurses is essential. Key
questions include: what are the issues and difficulties new graduate nurses encounter as they
make their transition into the nursing role? How can health care organizations assist in making
this change smoother for the new graduate? Pursuit of these questions provides a foundation
for ongoing improvement. Current studies validate the need for initial and continuous
assessment to uncover and address the issues and difficulties that exist among new graduate
nurses (Goode, Lynn, Krsek, & Bednash, 2009; Goode, Lynn, & McElroy, 2013; Little,
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Ditmer, & Bashaw, 2013; Trepanier, Early, Ulrich, & Cherry, 2012).
One way health care organizations have taken the necessary steps to support new
graduates in their transition from student to practitioner is by establishing new graduate nurse
residency programs with a preceptor component (Goode et al., 2013; Little et al., 2013; Ulrich et
al., 2010). The Carnegie Foundation supports the development of nurse residency programs in
their study on nursing education (Benner, Sutphen, Leonard, & Day, 2010) and the Institute of
Medicine (IOM) as a way to increase patient safety and maintain the quality of patient care
(IOM, 2010). Even with the implementation of these preceptor-based residency programs,
retaining new graduates has proven difficult and turnover rates remain high in the hospital setting
(American Association of Colleges of Nurses, 2015b; Robert Wood Johnson Foundation, 2014).
After reviewing published studies, and interviewing new graduates and their personal
experiences, the author designed this phenomenological qualitative study as a way to explore and
evaluate new graduate registered nurses’ lived experiences. This study was delimited to the
interactions of nurses and preceptors during a new graduate nurse residency program at Salem
Hospital in Salem, Oregon.
Organization of Thesis
This chapter contains an introduction to the problem under investigation, and a discussion
of the nature and types of issues encountered by new graduate registered nurses transitioning
into the profession. Chapter one also outlines the author’s position statement and personal
biases. The chapter also contains the purpose statement and research question, along with the
theoretical framework utilized to guide this research.
Chapter two describes the literature related to the components of new graduate nurse
residency programs, including the nurse’s role, mentorship development, and the nurse
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preceptor’s role. Major topics for this literature review include: workplace entry (both in general
and in relation to new graduates), issues of critical thinking, technical competency,
socialization/communication development, reality shock, and burnout. Chapter three provides a
description of the methodology applied in this phenomenological qualitative study. It also
provides a discussion of the participants, data collection and storage, data analysis, and the steps
taken to insure trustworthiness and validity of the study.
Chapter four details the process of data collection and analysis. Five themes emerged
from the data, including: communication and trust, management support, guidance and role
modeling, technical skill development, and improving confidence. Chapter five includes a
discussion of the findings, subsequent recommendations (both from the researcher and the
participants), and concluding remarks.
Statement of the Problem
This research study investigated the nature and type of issues new graduate registered
nurses face as they successfully transition from an academic program into the profession, and
how the preceptor can assist them in making this transition. The purpose of this study was to
examine the lived experiences of new graduate registered nurses’ interactions with their
preceptors during this transition; otherwise known as the orientation period. This study
identified the actions and behaviors, as well as traits and techniques, used by preceptors to
support the successful transition of new graduates, based on the verbal descriptions and
perceptions of new graduate nurses. The data could assist in the continuing development of an
effective preceptor teaching model, which will improve job retention and quality of care while at
the same time reducing turnover.
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The phenomenon of new graduate nurse transition has been widely examined (Aiken &
Clarke, 2003; Candela & Bowles, 2008; del Bueno, 2005; Dyess et al., 2009; Feng & Tsai, 2012;
Goode et al., 2013; Little et al., 2013; Orsolini-Hain & Malone, 2007; Rush, Adamack, Gordon,
Lilly, & Janke, 2013; Ulrich et al., 2010). Health care organizations have started to address
some of the issues new graduates face, including clinical competence, critical thinking, and
orientation; nonetheless, new graduates continue to encounter difficulties in making the
transition from student to professional (Chandler, 2012; Hoffart, Waddell, & Young, 2011;
Trepanier et al., 2012).
Past literature suggests new graduates are frequently lacking in critical thinking, technical
competencies, socialization/communication skills, and may also suffer from reality shock and
burnout, potentially putting themselves and their patients at risk (Baxter, 2010; Berkow, Virkstis,
Stewart, & Conway, 2009; Bolden, Cuevas, Raia, Meredith, & Prince, 2011; Brown, Neudorf,
Poitras, & Rodger, 2007; Casey et al., 2004; Duchscher, 2009; Garrett & McDaniel, 2001;
Killam & Heerschap, 2013; Laschinger, Finegan, & Wilik, 2009; Laschinger & Grau, 2012;
Rella, Winwood, & Lushignton, 2008; Rudman & Gustavsson, 2011). These areas of concern
are not limited to new graduates in the United States, they are an internationally recognized and
documented phenomenon (Anderson, Hair, & Todero, 2012; Blanzola, Linderman, & King,
2004; Boychuk Duchscher, 2009; Boychuk Duchscher & Myrick, 2008; Bratt, 2009; Cho, Lee,
Mark, & Yun, 2012; Clark & Springer, 2012; del Bueno, 2005; Duclos-Miller, 2011; Orsolini-
Hain & Malone, 2007; Salt, Cummings, & Profetto-McGrath, 2008; Thompson et el., 2014;
Valdez, 2008).
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Issues New Graduates Face
Critical thinking is often considered the foundation for making sound judgments and
decisions, and has been described as the art of exploring and assessing one’s thought processes
with the aim of improving one’s thinking (Gervey, Drout, & Wang, 2009; Paul & Elder, 2006;
Tümkaya, Aybek, & Aldaş, 2009; Valenzuela, Nieto, & Saiz, 2011). Nurses are required to
possess higher levels of clinical judgment and critical thinking skills than in the past (Lisko &
O’Dell, 2010), and are expected to have specialized skills encompassing a diverse set of
practices and functions based on research and theory (Tayray, 2009).
Technical competency in nursing can be interpreted as the clinical knowledge,
experience, and capabilities that are appropriate for carrying out assigned duties or for
performing as expected (Calhoun, Rider, Meyer, Lamiani, & Truog, 2009; Nelson, 2013). New
graduates must be deemed technically competent to provide the best possible standard of care
(Axley, 2008). In light of the rapidly changing state of biomedical equipment, nursing
procedures, and pharmaceuticals, new graduates must be prepared to face an ever-evolving and
advancing health care system as they assess, treat, and evaluate their patients’ health issues
(Buppert, 2012).
Successful socialization requires comprehensive continuous educational programs,
supportive working structures, professional and competent role models, opportunities for clinical
experience, and constructive feedback (Dinmohammadi, Peyrovi, & Mehrdad, 2013; Halstead,
2012). The outcome of positive professional socialization is role identity, organizational
commitment, and improved quality of care, with new graduates looking towards the preceptor as
a role model (Donaldson & Carter, 2005; Johnson et al., 2012; Loh & Nalliah, 2010; Perry,
2009; Weissmann, Branch, Gracey, Haidet, & Frankel, 2006). One of the core competencies for
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nurse educators and preceptors of The National League for Nursing is socialization (Halstead,
2012).
Reality shock among new graduate nurses has been the subject of numerous worldwide
studies. These studies have found increased stress and decreased confidence, poor job
satisfaction, and higher turnover rates from reality shock, which in turn can affect the retention
of new nurses, create financial burdens, and decrease both patient and employee safety (Caliskan
& Ergun, 2012; Clare & van Loon, 2003; Cowin & Hengstberger-Sims, 2006; Dizer, İyigŸn, &
Kiliç, 2008; Ewens, 2003; Kanogawa, 1986; Lei, Youn Hee, & Dong, 2010; Stacey & Hardy,
2011; Takase, Maude, & Manias, 2006). Multiple studies, specific to new graduates, have
concluded that negative work environments, poor transitions, and having little to no social
support leads to burnout and high turnover rates (Ilhan, Durukan, Taner, Maral, & Bumin, 2007;
Laschinger, Finegan, & Wilk, 2009; Lashinger & Grau, 2012) as high as sixty percent within the
first year of employment (Spence Laschinger, Wong, & Grau, 2012).
These same studies have found preceptor-based programs, incorporating both didactic
and social approaches, are a safe and organized way for new graduate nurses to identify, learn,
and master the technical and social skills they need to succeed (Ilhan, Durukan, Taner, Maral, &
Bumin, 2007; Laschinger, Finegan, & Wilk, 2009; Lashinger & Grau, 2012; Spence Laschinger,
Wong, & Grau, 2012). Based on these past results, this study explored the perceptions and lived
experiences of recent graduates to determine, in part: if they do in fact lack critical thinking
abilities, technical competency, and socialization/communication skills, whether they suffer from
reality shock and burnout, and whether preceptors made new graduates feel supported during
their orientation period. The results will be used to inform continuous improvement efforts,
reduce employee turnover, and to assure proper patient care and safety. This will decrease
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hospital costs, stabilize the nursing shortage, and enhance the first-year experience for graduate
nurses.
Significance of the Problem
According to statistics kept by Salem Hospital’s human resource department, the hospital
has experienced a turnover of new graduate nurses over the past five years, with 18% leaving
within two years of hire (J. Klaus, personal communication, September, 2015). This is keeping
in line with a national 10-year RN Work Project result of 17.5% of new graduate nurses leaving
their job within the first two years (Kovner, Brewer, Fatehi, & Jun, 2014). According to Bratt
(2009), up to 30% of new graduate nurses will change their place of employment within the first
year, costing organizations substantial financial loss. The estimated cost of recruitment and
acclimation of new graduate nurses is between $60,000 and $96,000 in orientation, salary,
benefits, and support (Anderson et al., 2012; Arnold, 2012). Additional studies strongly support
a preceptor-based residency program as a cost saving method for health care institutions by
reducing turnover (Baggot, Hensinger, Parry, Valdes, & Zaim, 2005; Beecroft, Dorey, &
Wenten, 2008; Contino, 2002; Jones, 2008; Krozek, 2008; Ulrich et al., 2010).
The American Association of Colleges of Nursing (AACN, 2015a) stated hospitals could
incur up to $300,000 in costs for every 1% increase in turnover each year. Goode et al. (2009)
found with adding a nurse residency program, turnover rates for residency graduates decreased to
5.7% compared to 35%–50% turnover for nurses who did not complete a residency.
Additionally, the AACN (2015a) reported a 94.3% retention rate for new graduate nurses who
complete a one-year residency program. This is a powerful statistic showing that a positive
preceptor-facilitated post-completion transition is a key component in retaining new graduates in
the nursing workforce (Duclos-Miller, 2011; Goode et al., 2009; Rush, Adamack, Gordon, Lilly,
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& Janke, 2013). New graduate residency programs can cost a hospital anywhere from $1,000 to
$3,000 per graduate (IOM, 2010), which is a small price to pay when hospitals are faced with a
50% to 80% turnover rate (Baggot et al., 2005; Beecroft et al., 2008; Ulrich et al., 2010).
Today’s health care system is changing at a rapid pace, as new technology and methods
of care delivery are constantly introduced. Health care managers are now seeing the stress of
these changes on their staff, along with the increased safety risks of orienting new graduates, and
the lack of preparation these new graduates have for the demands of the workplace (Cylke,
2012). While nursing schools prepare students by providing the basic foundations of nursing
care, it falls upon health care institutions (i.e., hospitals) to provide the continuing education new
graduates need, as well as providing a supportive, nurturing environment to ensure these new
nurses become safe and competent members of the health care team (Goode, et al., 2009; Lee,
Tzeng, Lin, & Yeh, 2009; Scott, Engelke, & Swanson, 2008).
One crucial aspect of a new graduate nurse residency program is the preceptor, who plays
a critical role for the new graduate during the program (Al-Dossary, Kitsantas, & Maddox, 2014;
Anderson et al., 2012; Barnett, Minnick, & Norman, 2014; Callaghan et al., 2009; Cockerham,
Figueroa-Altman, Ross, & Salamy, 2011; Croxon & Maginnis, 2009; Elmers, 2010; Gross
Forneris & Peden-McAlpine, 2009; Hoffart, Waddell, & Young, 2011; Marks-Maran et al.,
2013; McCarthy & Murphy, 2008; Murphy-Rozanski, 2008; Robitaillee, 2013; Rush et al., 2011;
Shinners, Mallory, & Franqueiro, 2013). A residency program combines an academic program
along with new skill training and competency development as supported by a preceptor.
Residency programs are devised to offer new graduates encouragement by way of feedback, and
assist new graduates in building supportive and collaborative relationships with other members
of the interdisciplinary health care team (Baxter, 2010; Berkow, Virkstis, Stewart, & Conway,
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2008; Boyer, 2002; Keller, Meekins, & Summers, 2006; Lampe, Stratton, & Welsh, 2011; Steen,
Gould, Raingruber, & Hill, 2011).
A preceptor is an experienced nurse, usually with some additional training in the
preceptor-based role, who provides one-on-one training and orientation to the new graduate (i.e.,
preceptee) as they transition into their new professional role (Brammer, 2008; Brown, Stevens, &
Kermode, 2012; Donner, 2007; Hsu, Lee, Fu, & Tang, 2011; Murphy, 2008; Putnam, 2010;
Swihart, 2007). The preceptor not only assists in the development of the new graduate’s clinical
skills, but also acts as a role model within the clinical setting, which is a critical component in
the professional growth of a new nurse (Allan, Smith, & Lorentzon, 2008; Bradbury-Jones,
Sambrook, & Irvine, 2011; Kilcullen, 2007; Lee, Cholowski, & Williams, 2002; Perry, 2009).
Benefit of Research
The data collected and analyzed from this research will have a positive effect on Salem
Hospital and the community it serves in a number of ways. Well-trained, dedicated nursing
personnel are in constant demand. As the baby boomer population starts to retire, fewer and
fewer experienced nurses will be available to participate in the preceptorship and mentoring of
incoming graduates. Thus, a residency program based on a preceptor-teaching model will make
a positive contribution to the development of proficient and self-confident staff. This, in turn,
will allow those who have completed the program to pass on their experience to new graduates in
the future.
New graduates will benefit from this research as well by having a say in the future
development of the residency program (via this study); thus, giving them a sense of belonging
and purpose within the organization (Bolden et al., 2011; Gavlak, 2007; Spence Laschinger,
Borgogni, Consiglio, & Read, 2015; Winter-Collins & McDaniel, 2000). The data gathered in
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this research will assist future new graduates in their development of critical thinking and new
technical skills (competencies) by assisting nurse educators and preceptors in the continuing
development of a residency program.
Another positive outcome for a residency program is the fostering of continuing
education and lifelong learning by the participants. Bratt (2009) found nurse managers were
delighted with the enthusiasm of residency graduates to further their education in various
programs, including specialty certification and nurse management courses. Nurses engaging in
these formal and informal education programs give stability to both the facility and the
individual nurse (Bratt, 2009). On a side note, Salem Health has earned the distinction of being a
Magnet hospital by the American Nurse Credentialing Center, making the qualities of leadership
and continuing education vital to maintaining Magnet standards (American Nursing
Credentialing Center, 2015).
Whether or not new graduates move on in their careers, they will have learned the skills
necessary to adapt and grow in any nursing setting they choose, which in turn will assist in the
global nursing shortage (Littlejohn, Campbell, Collins-McNeil, & Khaylie, 2012; McDermind,
Peters, Jackson, & Daly, 2012; Oulton, 2006). Bratt and Felzer (2012) found new graduate
nurses felt more committed to their organization when a residency program was part of their
orientation. Increased commitment can assist in easing the financial burden some hospitals with
a high turnover of new graduates face, as these new graduates are more likely to stay with the
organization. It is hoped this research will make a lasting impact on the development, retention,
and satisfaction of the nursing staff at Salem Hospital, while simultaneously improving patient
safety and quality of care (Bland Jones & Gates, 2007).
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Positionality Statement
Nursing, and all it entails, is one of the foundations of my personal and professional life.
Growing up, I always admired my mother, who is a nurse, as well as other various family
members for their compassion and caring manners. As a registered nurse, I belong to a special
community of caregivers, which I express when using my knowledge and skills. Now, as a
nursing instructor, I must go a step further and convey my love of nursing to my students,
through my experience and wisdom, who in turn must go out and contribute to the community of
nursing.
I am currently employed at a local nursing college, instructing first-year nursing students.
I assist in the selection of the most appropriate curriculum and methods of teaching to
accommodate different learning styles and the various learning environments at the college. I
am also tasked with demonstrating the impact of learning and development programs and
restructuring these programs as needed depending on the outcomes and future developments.
Previously, I was employed as the Professional Development Specialist (PDS) at Salem
Hospital. This was a nursing education role, covering the four critical care areas and respiratory
therapy unit. I was responsible for the initial and continuing education needs of more than 420
clinical staff members on these units. In this role, I also assisted in building the foundations of
the New Graduate Nurse Residency Program by developing and implementing curricula, be it in
lecture, computer-based, or skill lab formats.
In my past readings on education and teaching, I was particularly drawn to Bain’s (2004)
book, What the Best College Teachers Do, especially chapter four, “What do they expect of their
students?” This chapter really hit home for me when I was in the middle of assisting with the
restructuring of the hospital’s new graduate residency program. The three other individuals on
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the team wanted a very structured, lecture-style format. They did not want to take into
consideration the students; it was all about them as instructors. They expected the students to sit
in class, 6–8 hours a day for 3-weeks of “learning.” Teaching in this manner is very difficult for
me, as I place value on education and the needs of students before my own needs as an
instructor. I also feel that I am not an efficient instructor if all I do is lecture. I need class
participation, hands-on work, group work, and student feedback. This cannot be accomplished
in a lecture-only format. I have carried this philosophy with me as I transition from the clinical
setting to the academic arena.
To me, strict lecturing is one of the worst ways of teaching. Fennel and Arnot (2008)
stated that instructors must move from the didactic form of teaching to the facilitative form. As
instructors, we need to create an environment that is open, safe, neutral, and is conducive to
learning. Lecturing to students is not neutral; the instructor is in control and is just spoon-
feeding the students. While it is true, in today’s technologically-driven world, students want
their information as fast and as concise as possible, how does lecture-only allow for creativity
and the development of critical thinking?
Upon further reading of Bain (2004), I related to his section on creating a diverse learning
experience (p. 116-117). He viewed each student as different, with different learning styles and
needs. This was echoed by Jupp and Slattery (2010), especially from the point of view of white
male teachers (which I am a member). So, we should not use the same tool to measure everyone,
as there are different learning styles and ways of processing information, as discussed by Fennel
and Arnot (2008). As instructors, I believe we have to follow this mantra: everyone learns
differently. Identifying my biases as a scholar–practitioner can also assist in keeping an open
mind while I study new nurses and their interactions with their preceptors as they develop their
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nursing and interpersonal skills. Having been in the profession of nursing and training new
nurses as a preceptor, I bring not only my experience, but also my love for teaching and seeing
new nurses grow into contributing members of the profession. Being aware of my biases and
views on educating these students, I know I am in an excellent position to discover the variances
in literature and other programs and how I can contribute to making a difference in the further
education of new graduate nurses.
As the researcher of this study, I recognize that my personal experience and knowledge
as a preceptor could pose a potential bias during this study. I have been a preceptor for
numerous new graduate nurses during my career, from those who needed very little instruction to
those who could not function without me being by their side all day. Personally, I enjoyed those
new graduates who fell somewhere in the middle; those who were able to recognize what they
did not know and ask for assistance. Preceptorship does involve extra work, at least at the
beginning, as I try to establish a bond of trust between us, and it is always easier to perform the
task myself then to have the new graduate do it. Simply standing beside the new graduate and
observing can often be very demanding as well.
The new graduate who thinks they know everything and does not ask for assistance, in
my opinion, is not going to succeed and will likely put their patients’ lives at risk. This bias
toward overconfidence had to be kept in the forefront of my mind during the research. On the
flip side, I also have a bias toward the preceptor who believes the new graduate should already
know everything, does not offer support or guidance, or is perceived as unapproachable. This
sets up the new graduate for failure, and puts patients’ lives at risk as well.
Chenail (2011) stipulates qualitative researchers should have a design in place to prevent
personal bias from influencing the data. Throughout all phases of this study, I made a conscious
21
effort to acknowledge and separate my personal and professional attitudes and beliefs from the
study. I also made a conscious effort to refrain from interjecting my personal opinions, previous
knowledge, or experience while collecting the data and conducting the analysis (Creswell, 2013;
Glesne, 2011; Polit & Beck, 2013). I followed specific research guidelines as outlined by
Northeastern University and its institutional review board and consulted my committee when
questions arose to ensure I applied proper ethics in the data collection, transcription,
interpretation, and data analysis processes (Friga & Chapas, 2008).
Before beginning interviews with the participants, I reviewed the purpose and process of
this study with each individual and answered any questions before they signed consent forms. I
had not been the preceptor for any of the participants, which allowed them to talk freely and their
responses were not influenced by my presence. After each interview, I took time to reflect with
the participant on any questions that might have come up during the interview process. I
undertook personal reflection and recorded any thoughts in my journal that could potentially bias
the findings.
Research Question
The purpose of this phenomenological qualitative research study was to explore, identify,
and evaluate new graduate registered nurses’ lived experiences of interactions with preceptors
during the course of a residency program. Isolating the actions and behaviors of preceptors,
through verbal descriptions and perceptions offered by the new graduate, assisted in identifying
the traits and techniques utilized by effective preceptors during the new graduates’ progression
from student to professional. Identifying these positive traits can assist future preceptors training
of new graduates, confirm the benefits of the nurse residency program, help retain competent
22
nurses within the profession, and most importantly, improve patient safety. To examine this
issue, the following question was addressed:
How do new graduate registered nurses’ describe their experiences with preceptors
during the orientation period of a new graduate nurse residency program?
Theoretical Framework
Benner’s (1984) grand nursing theory, Novice to Expert, provides the theoretical
framework for this research. Benner’s model grew out of the Dreyfus (1980) experiential
learning skill acquisition model, which viewed improvements in nursing practice as being
dependent upon experience and science (Benner, 2004). Benner’s theory of learning stated that
learning not only occurs during the collaboration between new graduates and preceptors, but also
during the entire professional life of the nurse, as the nurse is expected to maintain their
competencies for licensure and practice. Benner’s theory applies to the changes that occur when
the new graduate progresses through phases of unfamiliarity, starting as a novice nurse and
working into, hopefully, becoming an expert nurse. Subsequent research has expanded on
Benner’s novice to expert theory, adding to the existing body of knowledge surrounding the
profession of nursing (Cappel, Hoak, & Karo, 2013; Dale et al., 2013; DeSandre, 2014; Gentile,
2012; Mann-Salinas et al., 2013; Spiva et al., 2013).
Benner expanded on the concept of experiential learning to moral and ethical decision
forming, developing helping relations, and how the experiential learning process influences those
decisions. When a patient is experiencing a health issue, it is up to the nurse to make the
distinction between the continuum of care, comfort, control, and suffering. These choices are
influenced by the context and the relationship the nurse has with the patient (Benner, 1984).
Qualitative distinctions require an emotional adjustment that cannot be made through textbook
23
knowledge alone. A relationship between patients and nurses requires trust and open
communication, and to establish this policy, protocols must be examined and individualized for
each patient. This is where the preceptor teaching model plays an important part in the new
graduates’ entry into practice. The preceptor can provide support and expertise so the new
graduate does not have to learn these traits by trial-and-error. According to Benner (2001b),
skilled know-how and ethical practice are the hallmarks of a good practitioner, and learning how
to respond during the actual encounter with the patient is experiential learning.
Benner’s Model of Novice to Expert
Benner’s theory differentiated five levels of nursing experience: novice, advanced
beginner, competent, proficient, and expert. These five stages identify nurses’ growth in
knowledge and skill as they gain more experience and represent their progression from novice to
expert, with each stage building upon the knowledge and skills learned in the previous stage
(Arreciado & Pera, 2015; DeSandre, 2014; Dracup & Bryan-Brown, 2004; Koontz, Mallory,
Burns, & Chapman, 2010).
Benner’s theoretical model dovetails comfortably with Kolb’s model of experiential
learning. According to Kolb (1984), “Learning is the process whereby knowledge is created
through the transformation of experience” (p. 38). Kolb believed emphasis should be placed on
the process of growth, adaption to the situation or environment, and what is being learned rather
than a specific outcome. Kolb also believed that knowledge is a transformation process and
learning transforms the experience in both its subjective and objective forms (Kolb, 1984). Kolb
(2005) stated that learning occurs in the presence of two processes: (a) grasping or understanding
the event, and (b) transforming the experience, which in turn is how nurses progress from novice
24
to expert within Benner’s theoretical model of development. Each of Benner’s five stages are
briefly discussed below.
Novice. In the beginning, the new graduate has no significant practical experience
related to the clinical environment. A novice nurse is focused on achieving a set of goals and
developing rapport with the patient. Such a narrow focus inhibits their ability to see the “big
picture.” They have not had the experience of caring for enough patients to realize when a
patient is taking a turn for the worse.
New graduate nurses start in the novice stage, as they are utilizing the facts they have just
learned in school to guide their actions, and tend to be limited and unyielding when it comes to
contemplating the complexity of a situation (Arreciado & Pera, 2015; Carlson, Crawford, &
Contrades, 1989). Novices are limited in their confidence, lack basic critical-thinking skills, and
possess limited clinical judgment. As a result, they have difficulty multi-tasking and seeing the
big picture, are fixated on performing specific tasks, and tend to rely on straight memorization
for knowledge growth. Tell the novice nurse what to do, and they will do it without
understanding why it should be done (Alligood & Tomey, 2010; Petit dit Dariel, Raby, Ravaut,
& Rothan-Tondeur, 2013).
Those working with novice new graduate nurses should take into consideration that this
population will have difficulty organizing and prioritizing tasks, such as patient care, as they are
learning to translate their new knowledge into experience (Anderson et al., 2012; Blanzola et al.,
2004; Bratt, 2009; Clark & Springer, 2012; del Bueno, 2005; Ironside, McNeilis, & Ebright,
2014; Orsolini-Hain, & Malone, 2007; Salt et al., 2008). Preceptors should focus their teaching
on helping the new graduate become competent in their skills and confident in themselves; and
they can accomplish this by assisting the new graduate in learning to set priorities, recognize
25
medical trends in patients, distinguishing important information from non-important information,
and developing confidence in themselves as nurses (Croxon & Maginnis, 2009; Elmers, 2010;
Gross Forneris & Peden-McAlpine, 2009; Koontz et al., 2010; Robitaille, 2013). The data for
this study came from this group of novice nurses.
Advanced beginner. The advanced beginner is a new nurse who has completed their
orientation and is in the first few years of independent practice and whose performance is
marginally acceptable (Hnatiuk, 2012). In this phase, the new nurse is able to recognize
recurring meaningful events due to having observed situations during nursing school and as a
novice nurse. Educators should be aware that the advanced beginner new graduate nurse views
all aspects of care equally and does not recognize priorities as they arise. This can, obviously,
have a damaging effect on patient care (DeSandre, 2014; Koontz et al., 2010).
Competent. By this phase, the nurse has been practicing for two to three years and
possesses the ability to perform independently and safely. They possess insight and have the
comprehension and aptitude to make the distinction between life threatening and non-life
threatening information. The nurses’ clinical experiences strongly contribute to this development
level (Koontz et al., 2010). A competent nurse can focus on different aspect of the patient and feels
comfortable managing multiple patients. The nurse is now beginning to feel more comfortable
with planning and time management skills, and has confidence in their actions, but still lacks
visualization of the whole picture (Arreciado & Pera, 2015; Koontz et al., 2010). The competent
will progress to the proficient stage as they continue to experience situations, process and learn
from the knowledge they have gained.
Proficient. The proficient nurse observes and processes situations fully, instead of in
singular steps in order to accomplish a task. This assists the nurse in decision-making and serves
26
as a guide, while at the same time enables the nurse to remain flexible depending on the
condition of the patients (Dale et al., 2013; DeSandre, 2014; Koontz et al., 2010). At this stage,
the nurse possesses the ability to step back and look at the whole picture based on previous
experiences, and can anticipate and recognize subtle patient cues before they become critical
(Koontz et al., 2010).
Expert. During the fifth stage, the expert nurse no longer relies on guidelines to
comprehend the patient’s condition, is able to react more quickly, and take the appropriate
actions. The expert nurse has enough experience to act more intuitively, quickly comprehending
the data at hand and drawing conclusions without considering all of the possible alternatives.
When facing the unknown, they are able to solve problems analytically (Benner, 2004). The
expert nurse is more attuned to particular concerns in the clinical situation; they see the big
picture, understand potential complications, and are able to evaluate ethical issues to arrive at a
plan of care. Benner (2004) suggested that the new graduate nurse transitions from a confused or
vague understanding to a clearer understanding that seeks to eliminate errors, and clarifies the
limits and possibilities in the situation. The expert nurse has now accrued extensive experience,
can demonstrate clinical reasoning, and is able to anticipate the unexpected because they
comprehend what is needed and why (Koontz et al., 2010).
Dracup and Bryan-Brown (2004), state expert nurses do not rely on the technical task-
orientation process that is the focus for the novice. An expert nurse uses critical reasoning and
judgment to modify care based on the changing condition of the patient. Expert nurses are
ideally poised to become preceptors themselves, thereby advancing their own clinical and
professional practice (Dracup & Bryan-Brown, 2004).
Benner’s nursing model emphasizes the importance of clinical nursing as the foundation
27
of the design. The model also advocates that observation and emulation of preceptor actions is
the preferred method of learning. Preceptors are nurses who have already gained the
experience to function at a higher level than the novice. This provides an opportunity for the
novice to study the actions and thought process of the expert nurse. An opportunity to observe
the actions of an expert nurse allows the novice nurse to expand their scope of practice in a
more confident manner (Benner, 1984).
Penprase’s (2012) research acknowledged the importance of preceptorships, which is
relevant to this study because it indicates preceptorship and orientation programs make a
significant impact on empowering new graduates for success. It also supports Benner’s Theory
of Novice to Expert by describing the importance of an active preceptorship program in the
transition from a student nurse to a Registered Nurse. By utilizing Benner’s theory as the
theoretical model for this study it allows the researcher to further explore ways preceptors can
assist new graduate nurses in the clinical learning and how they can apply theoretical
knowledge to clinical situations (Schaubhut & Gentry, 2010).
Summary
Hospitals are now developing their own new graduate residency programs to assist new
graduate nurses in bridging the gap between academia and the clinical arena. By developing a
new graduate residency program, with a preceptor-based teaching model, the health care
organization is providing the support the new nurse needs in their transition, retention, and
continuing development of skills within the organization. By providing a safe and structured
educational experience, preceptorships may assist in reducing new graduate nurses’ reality
shock, burnout, and turnover; thus, improving the retention rate of new graduate staff. In
conjunction with the ongoing development of the program, objective ways of measuring the
28
program’s success and contribution to the organization need to be established. Measuring the
effectiveness of a preceptor-based teaching model in terms of its outcomes, processes, and long-
term impact on practice is crucial for the success of these programs.
Experiential learning is involved in every aspect of nursing education. It is the essence of
the transition from a student to practitioner, and what enables the nurse to practice with
confidence in their decision-making ability. Consequently, Benner’s grand nursing theory of
novice to expert provides a sound theoretical framework for this study. Having a clear and
precise preceptor-based program in place will allow scholar-practitioners the opportunity to
gather data on the effectiveness of nurse residency programs and make any changes if needed.
Thus, benefiting not only participants, but also the organization and nursing profession as a
whole.
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Chapter Two: Literature Review
This phenomenological qualitative research study explored and evaluated new graduate
registered nurses’ actual lived experiences of preceptor interactions during the course of a new
graduate nurse residency program. Isolating the actions and behaviors of preceptors, through
verbal descriptions and perceptions of the lived experiences of new graduates, assisted in
identifying the traits and techniques used by effective preceptors when training new graduate
nurses. It is hoped this information will have a positive impact on employee retention and
clinical competency. This literature review begins with an overview of some the different
aspects of the nurse’s role, including the concept of mentorship, and a discussion of the nurse
preceptor. The chapter continues with a discourse on workplace entry, both in general and
pertaining to new nurses, and the issues surrounding new graduate turnover. The chapter
concludes with an exploration of the issues facing new graduate nurses, including: critical
thinking, technical competency, confidence improvement, socialization/communication
development, reality shock, and burnout. This will be followed by a summary of the discussion
thus far.
Aspects of the Nursing Role
The professional nursing role has been described as both and art and a science (Locsin,
2013; Norman & Ryrie, 2013; Sheets, 2012), and includes different qualities that are called into
play based upon the work situation. One of these roles involves acting as a caregiver, where the
nurse strives to prioritize and meet the needs of their patients as well as demonstrates necessary
technical competencies, ethical considerations, and critical thinking skills (Krueger, Funk,
Green, & Kuznar, 2013). Another role assumed by the nurse involves working as an organizer
and developing care plans specific to each patient. The nurse must be able to determine which
30
factors influence the need for care, know and determine how this care should be carried out,
either by the nurse or delegated to others, and have the ability to coordinate and implement the
plan of care (Alberto et al., 2014).
The nurse utilizes evidence-based policies and practices to influence the care provided to
the patient. The nurse focuses on innovation and quality improvement, as well as being aware of
current research, and utilizing critical thinking in the care of their patients (Hood, 2014; Kuznar,
2012). Moreover, in their role as health care professionals, the nurse is part of a larger team,
regularly interacting with other members of the health care team. The nurse must be able to
work with a variety of staff from different disciplines, such as physical therapy, occupational
therapy, speech pathology, and registered dietitians (Lees, 2013; Yoder-Wise, 2015).
Finally, the nurse takes on the role of coach. This includes motivating and stimulating
staff, giving feedback to peers, or acting as a preceptor with new staff (Minnick et al., 2008). A
professional nurse is defined by possessing the ability to incorporate all of these roles, as well as
knowing how and when to prioritize them (Finkelman & Kenner, 2014; Masters, 2014). The
preceptor plays an important role in assisting the new graduate in developing these first two
crucial roles of caregiver and organizer. If the new graduate cannot master being a caregiver and
organizer, they will not be able to progress successfully in the profession.
Mentorship
The literature describes the term “mentoring” at length. In the ground-breaking book The
Seasons of a Man’s Life, a mentor was defined as someone who is able to provide moral,
emotional, and psychosocial support to another individual (Levinson, Darrow, Klein, Levinson,
& McKee, 1978). Twenty years later, Campbell and Campbell (1997) explored the perspective
of mentoring in the workplace, in which an experienced member of the organization guided and
31
supported newer staff members, thus leading to a more productive organization. Mentoring has
also been discussed in the fields of business (Purcell & Scheyvens, 2015; Srivastava & Jomon,
2013; Waters, McCabe, Kiellerup, & Kiellerup, 2002), medicine (Bauman, 2007; Kashiwagi,
Varkey, & Cook, 2013; Wright, Dirsa, & Martin, 2002), education (Haas, 2012; Hobson, Ashby,
Malderea, & Tomlinson, 2009; Larkin, 2013; Le Maistre & Paré, 2010), and psychology (Canter,
Kessler, Odar, Aylward, & Roberts, 2012; Crisp & Cruz, 2009; Laschober, Eby, & Kinkade,
2013). Following a meta-analysis, Eby, Durley, Evans, and Ragins (2008) proposed that
mentoring relationships assist in providing positive outcomes for novices entering the field, such
as higher job satisfaction and support from management. According to Jacobi (1991), people
enter a mentorship for a number of reasons, including growth on a personal level, to gain
professional advice and growth, or to find a support structure.
Mentors can offer professional guidance in the form of emotional support, as well as
being a positive role model to the novice, giving constructive feedback, and demonstrating
appropriate behavior (Allen, Eby, & Lents 2006; St-Jean & Audet, 2009). Mentors are chosen
either by the individual or the organization because they have the knowledge and experience to
guide the mentees on their new journey (Awaya et al., 2003). Mentors can act as guides and
assist in shaping the behaviors of the novice through the course of their career and can offer
emotional, social, and psychosocial support in the forms of acceptance, counseling, coaching,
friendship, visibility, protection, and offering challenging assignments (Betts & Pepe, 2006; Eby,
Allen, Evans, Ng, & DuBois, 2008; Eby & Lockwood, 2005; Wanberg, Kammeyer-Mueller, &
Marchese, 2006). Mentors should be selected not only for their technical expertise, but also for
their experience and knowledge of the organization (Cull, 2006; St-Jean & Audet, 2009).
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Mentoring in health care. Mentorship plays an important and vital role in the health
care setting, where it influences career progression, employee satisfaction, and employee
retention (Brunetto, Farr-Wharton, Shacklock, & Robson, 2012; Finley, Ivanitskaya, Kennedy, &
Hofmann, 2007; Huang & Weng, 2012). The American College of Healthcare Executives has
developed numerous formal mentoring programs with experienced executives that include such
aspects as job shadowing, continuing educational programs, and personal progression plans for
those wishing to climb the corporate ladder (Weil & Zimmerman, 2007).
One of senior health care management’s duties is to identify potential successors and to
groom them for future promotion by acting as a coach and mentor (Dubiel, 2013; Hicks &
McCracken, 2010). Both formal and informal health care mentoring programs have been
discussed in the literature, with some studies indicating that senior executives are more likely to
serve as mentors if an established formal program exists (Finley et al., 2007); while other studies
report a more informal approach lends itself better to health care (Finley et al., 2007; Hicks &
McCracken, 2010).
The nurse as preceptor. The conceptual framework of a preceptor with educational and
administrative support has been proven to enhance the clinical competences of new graduates
(Shinners, Mallory, & Franqueiro, 2013; Singer, 2006; Ulrich et al., 2010). Preceptors are
experienced nurses who provide teaching and support while sharing their expertise and clinical
knowledge with the new graduate. The preceptor also facilitates socialization and objectively
evaluates and critiques the new graduate, while simultaneously acting as a professional role
model (Myrick, Yonge, & Billay, 2010; Shinners et al., 2013; Ulrich et al., 2010).
Preceptors also provide guidance to develop the clinical reasoning and critical thinking
skills of new graduates, develop technical skills, build the confidence of new nurses (Billings &
33
Halstead, 2012; Shinners et al., 2013), and make the transition from novice to advanced beginner
(Benner, 1982, 1984). A preceptor accomplishes this by offering collaboration, emotional
support, constructive feedback, and by building a professional bond between the new graduate
and themselves (Myrick et al., 2010; Shinners et al., 2013). Foley, Myrick, and Yonge (2013)
noted that preceptorships also decrease horizontal violence and create a safer working
environment in which the new graduate can raise questions without fear of reprisal. However,
without a strong positive relationship between the new graduate and the preceptor, the
experience will not be productive and could actually have negative effects for both the preceptor
and the new graduate (Duteau, 2012; Yonge, Myrick & Ferguson, 2011).
According to Berkow et al. (2008), new graduates currently make up around 10% of the
nursing workforce in most hospitals. Decisions on hiring new graduates are influenced by cost,
policy, and organizational needs, which include turnover rates. The higher the turnover rate, the
higher number of vacancies, which can put added stress on preceptors and other staff. The
number of preceptors is usually fixed and does not fluctuate in response to the organization’s
turnover rate. Additionally, many preceptors “often felt the full weight of responsibility for a new
nurse’s experiences” (Shermont & Krepcio, 2006, p. 409). A vicious cycle can soon develop in
which units, already suffering from staff shortages, employ new graduates who may require
longer periods of orientation, thus taking up more of experienced preceptors’ time. Invariably, a
certain percentage of the new graduates will leave before the end of the year, thus perpetuating
the shortage of nursing staff, which only further complicates this precarious situation. Many
articles reference this revolving door, which exerts an “emotional toll experienced by senior
nurses” (Shermont & Krepcio, 2006, p. 409).
34
The literature is conflicted regarding the nature of the relationship between preceptor and
preceptee (new graduate). Some authors feel it should be kept on a professional level, while
others feel there should be some form of personal connection (Moore & Spence Cagle, 2012).
Ultimately, however, a good match between the preceptor and preceptee must be established
based on learning and teaching styles (Callaghan et al., 2009; Croxon & McGinnis, 2009;
Ironside et al., 2014; Papathanasiou, Tsaras, & Sarafis, 2014; Tiwari et al., 2005), assessment
and clinical skill strategies (Duteau, 2012, McCarthy & Murphy 2008), critical thinking
development (Carlson, Wann-Hansson, & Pilhammar, 2009; Gross Forneris & Peden-McAlpine,
2009), and role modeling (Baldwin, Mills, Birks, & Budden 2014; McClure & Black, 2013). As
new graduates complete residency programs with their preceptors, they become more competent
and prepared to deal with the challenges of the workplace (Cappel et al., 2013; Caramanica &
Feldman, 2010; Clark & Springer, 2012; DeSilets, Dickerson, Shinners, Mallory, & Franqueiro
2013; Goode et al., 2009).
In order to examine the perceived competence of students and newly graduated nurses,
Lofmark, Smide, and Wikblad (2006) surveyed 106 senior nursing students who were ready for
graduation and 136 nurses who had experience as preceptors. Experienced nurses rated only
58% of the new graduate nurses as competent, whereas the student nurses gave the same group a
70% rating. This indicates the presence of two issues: (a) student nurses measure competence
differently, and they may not have an understanding of the role and responsibilities of a nurse;
and (b) experienced staff that are working as preceptors felt that 42% of graduate nurses were not
competent in patient care.
As discussed above, many different aspects of preceptorship must be taken into
consideration when assigning a new graduate to a preceptor. Consequently, Rodrigues and Witt
35
(2013) suggested a need for formal preceptorship training programs founded on pedagogical
principles. This lends credence to the observation of Eddy (2010), who stated that formal
preceptorship training has not yet caught up with the needs of preceptors. Bradley et al. (2015)
noted that preceptors should be continually evaluated; not only by the management, but also by
the preceptees, and that a strong preceptor-training program is vital for new graduates to succeed.
Preceptorships have also been shown to reduce staff turnover and increase job satisfaction, while
simultaneously preparing new graduates to assume leadership roles in the future, all of which
leads to better patient outcomes (Bland Jones & Gates, 2007; Duteau, 2012; Morgan, Mattison,
Stephens, & Medows, 2012; Rodrigues & Witt, 2013; Shinners et al., 2013; Singer, 2006).
Workplace Entry and Turnover
Two main themes emerged concerning the challenges faced by new graduates from
reviewing the literature on workplace entry or college-to-career transition. The first theme
concerns the personal challenges new graduates encounter. This can be as simple as moving to a
new location, learning to manage a budget, making new friends, and/or developing a new social
or religious network (Polach, 2004). The second theme concerns the various professional
challenges new graduates may face. In Wendlandt and Rochlen’s (2008) extensive literature
review, they identified the most common professional challenges new graduates face while
transitioning into a working environment: anticipation, adjustment, and achievement. The
authors developed a three-stage, college-to-career transition model, inclusive of: (a) a change in
philosophy associated with the transition between academia and practice; (b) the new graduate’s
lack of experience and skills, both technical and non-technical, as required by employers; and (c)
the new graduate’s misunderstood expectations about work life or reality shock.
36
While most new graduates face similar adjustment issues in making the transition from
academic to professional lives, how the new graduate responds to these challenges varies from
one individual to the next (Murphy, Blustein, Bohlig, & Platt, 2010). A qualitative study
performed by Murphy et al. (2010) explored new graduates’ ability to adapt to their new
surroundings. The researchers found that new graduates were better able to adjust to changes in
their work and living environment when they were able to identify realistic expectations and
were flexible in their approach to the job market.
New Nurse Graduates’ Entry into the Workplace
New graduate nurses face many obstacles in their transition from the academic to the
clinical arena. Casey et al. (2004) noted a dip in new graduates’ confidence around the third and
twelfth month of starting their professional practice and that their confidence did not improve
until after their first full year of practicing as a registered nurse. Therefore, the literature
indicates that it can take at least one year for a new graduate nurse to become comfortable in
their job due to specialization and changes in technology (Blanzola et al., 2004; Goode et al.,
2009; Halfer et al., 2008; Wangensteen, Johnson, & Nordstrom, 2008). In another study, Fink,
Krugman, Casey, and Goode (2008) noted the job satisfaction of new graduates dropped 6-
months after being hired. Several reasons for this are possible, including the new graduate’s
interaction with their preceptors’ supervision, their development of critical thinking and new
skill acquisition, as well as learning new organizational and communicational skills (Casey et al.,
2004; Delaney, 2003; Etheridge & Haggblom, 2007; Fink et al., 2008). The feeling of being
overwhelmed in taking care of patients was also high on the new graduates’ list of stressors (Al-
Dossary et al., 2014; Casey et al., 2004; Cho et al., 2012; Cowin & Hengstberger-Sims, 2006;
Etheridge, 2007; Kovner, Brewer, Wu, Cheng, & Suzuki, 2006; Yeh & Yu, 2011).
37
Delaney (2003) identified ten themes among new graduate nurses in relation to starting
out in the nursing profession. These included:
• learning the system and culture shock;
• feeling stressed and overwhelmed;
• possessing mixed emotions;
• welcome to the real world;
• the power of nursing;
• dancing to their own rhythm;
• preceptor variability;
• unprepared for dying and death;
• stepping back to see the view;
• ready to fly solo.
Experiencing stress was the most common of the themes and related to all aspects of the
orientation process. As the new graduate gained new skills and confidence, their reported stress
level began to diminish.
Graduate Nurse Turnover
Employee turnover threatens the ability of an organization to maintain a stable
workforce. Hunt (2009) reported a 27% turnover rate for new graduate nurses within their first
year of employment. The National Council of State Boards of Nursing (Ulrich et al., 2010)
reported that 26% of new graduate nurses leave their jobs in the first two years of employment.
Dion (2012) reported that 18–60% of new graduate nurses leave the acute care environment
during their first year of employment, possibly due to the high level of clinical skills required for
such an environment, thus leading to higher levels of stress (Newton & McKenna, 2007). Other
38
studies have identified stress as a leading cause of graduate nurse turnover (Duffield, Roche,
Blay, & Stasa, 2010; Grochow, 2008; Morrow, 2009; Yeh & Yu, 2011).
Cowin and Hengstberger-Sims (2006) investigated the relationship between the
developing self-concept of new graduate nurses and their intention to remain in their current
place of work. The investigators suggested that organizations look at ways to assist the new
nurse develop a sense of purpose and well-being; thus, increasing retention, as well as
developing highly trained and competent nurses.
Cho et al.’s (2012) survival analysis study found the turnover rate to be at 17.7% within
the first year of hire for new graduates, by two years the turnover rate was 33.4%, and 46.3% by
three years. These findings are consistent with those of the IOM (2010) and Kovner et al.
(2014). Cho et al. (2012) attributed such a high rate of turnover to stress, job satisfaction,
interactions with peers, and issues of self-worth—issues previously identified by Delaney
(2003); Lai, Peng, and Chang (2006); and Yeh and Yu (2011). Yeh and Yu (2011) identified
work stress as a major contributor to new graduates leaving within the first year of hire, and
challenged organizations and managers to find ways of improving conditions to alleviate the
sense of stress experienced by new graduates.
Parker, Giles, Lantry, and McMillan (2014) administered an online survey to 282 new
graduate nurses, with question items related to current employment, prior healthcare experience,
issues surrounding transition into practice, confidence in practice, and job satisfaction. Data was
analyzed using chi squared contingency tables and Kruskal-Wallis one-way analysis of variance
to predict to a significance of 0.05. Focus groups, lasting 60–90 minutes, were conducted with
55 new graduates, focusing on the transition experiences regarding support, workload,
expectations, intent to stay, relationships, and career opportunities. Nearly 10% of the
39
participants reported they were considering leaving nursing all together and only 2% intended to
stay two years in the profession. The new graduates identified a large incongruity between the
amount of support provided by their hospitals and the amount of support they felt they needed.
The new graduate nurses felt pressure form the hospitals to be working independently with a
minimum amount or training. This perceived lack of training and support resulted in low
retention and job satisfaction. This study supports the need for formal residency programs that
provides comprehensive positive experiences for new graduates who are balancing the stresses of
adapting to a new workplace, increased workload demands, and emotional strains of taking care
of patients (Parker et al., 2014).
Jones (2008) found the cost associated with nurse turnover averaged $65,000 per lost
nurse. This includes the cost of refilling these vacancies, the orientation for new hires, and the
loss of organizational productivity. By developing effective transition strategies, with preceptors
playing a key role, employing heath care organizations can potentially reduce the stress of new
graduate nurses and assist in job retention.
Issues New Graduates Face
Making the transition from student nurse to a new graduate nurse can be a tremendous
and worrisome experience. Too often the new graduate leaves the academic setting with the
foundational knowledge of basic nursing skills, but lacks skills in critical thinking, technical
competency, personal confidence, and the necessary socialization and communication skills to be
successful in the clinical setting. Without support from the employer, such as skills training, and
personal and emotional support, the new graduate can become bewildered, discouraged, and
generally disillusioned with their career choice, thus leading to higher levels of stress, reality
shock, and burnout. Park and Jones (2010) found this same phenomenon, stating that many new
40
graduates leave their place of employment within the first year due to poor training, a lack of
support systems, intense working environments, and higher patient acuity then they anticipated.
The following subsections will address these main issues individually.
Critical Thinking
No consensus exists in the literature on the definition of critical thinking. It appears
easier to define how a critical thinker behaves than to define the concept itself. Nosich (2012)
described critical thinking as the approach to developing alternatives, envisioning alternate
options, and anticipating consequences, all while keeping goals in sight. Paul and Elder (2006)
broke down critical thinking into two broad categories: analyzing thinking and assessing
thinking. The authors described the critical thinker as someone who asks vital questions and sees
potential problems, gathers, assesses, and clearly formulates relevant information using abstract
ideas to interpret the data effectively within alternative systems of thought, tests ideas against
relevant criteria and standards, and effectively communicates with others.
Critical thinking requires one to be heedful and amenable to understanding various
viewpoints in order to consider other perspectives (Facione, 2010). Additional definitions of
critical thinking include making sound judgments through reasoning; careful weighing of
evidence while skillfully synthesizing and evaluating information to arrive at the best solution to
a problem; and utilizing the skills of questioning, analyzing evaluating, reasoning, reflecting, and
believing (Abrami et al., 2008; Alwehaibi, 2012; Carlson, 2013; Paul & Elder, 2009). More
precisely, critical thinking is a systematic method of examining thinking, with the end goal of
improvement.
Carmichael and Farrell (2012) utilized a mixed methodology approach to investigate
students’ experiences of learning and their actual use of critical thinking. An interactive
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Blackboard website at the University of Western Sydney was developed for students to log into,
both independently and as a discussion group, to assist in the students’ development on the
concept and practice of critical thinking. This website contained nursing case study modules the
students could complete, as well as an interactive chat room where students could communicate
with each other. Information from 2006 and 2009 was gathered by a questionnaire, which was
then followed-up by semi-structured telephone interviews, and each component was analyzed
thematically. Seventy-three percent of the responders to the questionnaire (n = 113) indicated
that the site was useful in terms of understanding critical thinking.
The acquisition of critical thinking skills is considered the cornerstone of any nursing
preparatory program. By utilizing the knowledge acquired during their nursing course as a
foundation, along with the clinical experience acquired during orientation, the new graduate
continues to develop their critical thinking skills, and by applying these skills, the new graduate
is able to learn to manage complex patients (Kaddoura, 2010). Anderson et al. (2012), in a
systematic review of the literature, found evidence of improved critical thinking, behavioral
performance, and nursing skill competency over time, irrespective of the type of nurse education
that was offered. Additionally, while reviewing a problem-based learning new graduate
program, Applin, Williams, Day, and Buro (2011) reported that the program supported the
development of new graduate competency, thus encouraging the residents to become critical
thinkers.
Using structured student evaluations, Beyea, Von Reyn, and Slattery (2007) reported on
the efficacy of a simulation-based residency program. The investigators reported that a high
fidelity simulation-based residency program not only strengthened the new graduates’
assessment and clinical skills, but also enhanced their ability to apply critical thinking to patient
42
care and reduced the overall resource investment spent on orientation, thus saving the hospital
money. New graduates reported that the debriefing sessions in the simulation lab assisted them
in acquiring self-reflection skills, while the feedback from their peers assisted in
developing/improving critical thinking skills.
Kowalski and Cross (2010) used multiple measurement scales to review residency
outcomes, including: the Preceptor Evaluation of Resident form, the Pagana Threat score, the
Spielberger State-Trait Anxiety Inventory, and the Casey-Fink Nurse Experience Survey. An
analysis of the data revealed significant improvements among new graduate nurses enrolled in
residency programs in relation to setting priorities, knowing their limits, discerning urgency,
anticipating and implementing appropriate nursing interventions, and adapting patient’s care
plans based on actual outcomes.
In another study performed by Marcum and West (2004), new nurse graduates,
preceptors, and at least one member of the nursing staff from the unit where the graduates were
assigned to work, completed evaluations one year after program completion. The results
demonstrated that 83.3% of the residency participants displayed very strong critical thinking
skills and the remaining 16.6% still scored in the positive range for critical thinking. Critical
thinking enables new graduates to make sound, informed decisions and judgments, which in turn
has the potential to enhance the quality of a patient’s care (Crenshaw, Hale, & Harper 2011;
Dowding et al., 2012; Lim, 2011).
Technical Competency
As with the term critical thinking, no consensus on the definition of competency exists
either. Competency was first discussed by McClelland (1973) during a study of human
performance, and was perceived as observable human actions as opposed to an assumption of the
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action. Observable meant there was a way to measure and capture the actions, which in turn
allowed an educator to be able to develop a curriculum and teach those actions to others for
potential growth and/or improvement. A further definition of competency involves having the
required skills, retained or learned, necessary for the individual to successfully perform their
duties as outlined in their job description (Elliott & Dillon, 2012).
The development and assessment of competency within the workplace is not restricted to
nursing. Higher education (Johnstone & Soares, 2014; Panel, I.E.C.E., 2011), counseling
(American School Counselor Association; 2012; Sue, Zane, Nagayma Hall, & Berger, 2009),
accounting (Boritz & Carnaghan, 2003), informatics systems (Kaltoft, Nielsen, Salkeld, &
Dowie, 2014; Rodger & Bhatt, 2014), and multi-national corporations (Ulrich, Brockbank,
Younger, & Ulrich, 2012; Wang, Turnbull-James, Denyer, & Baily, 2014) all focus on the
training and advancement of their staff’s technical skills.
A review of literature describes competencies as the result of integrative learning
experiences in which combinations of skills, abilities, and knowledge are applied through
demonstration in measurable levels of performance (Adelman, Ewell, Gaston, & Schneider,
2014; ANCC, 2015; Gay, Mills, & Airasian, 2011; Pearce & Offerman, 2010; Kennedy, Hyland,
& Ryann, 2009). These can include: training and organizational development; knowledge of
subject matter; client management and relations; ability to solve problems; effective
communication skills; recruiting, ability to set priorities and use time effectively; and internal
relations (Fernandez et al., 2012; Gay et al., 2011; Johnstone & Soares, 2014; Klein-Collins,
Ikenberry, & Kuh, 201; O’Donoghue & Chapman, 2010).
The Nurse Executive Center (2007) conducted a large study of graduate nurse
performance. A survey was sent to 53,000 Chief Nursing Officers, asking them to rate the
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proficiency of new graduate nurses on 36 individual competencies and to consider the graduate
overall. The 5,700 responses to the survey were then broken down by nursing position: director
(9%), nurse educator (12%), charge nurse (17%), clinical nurse specialist (7%), nurse manager
(33%), and experienced staff nurse (23%). Only 10% of Chief Nursing Officers surveyed felt
that their graduates were providing safe and effective patient care. Therefore, 90% of hospital
nurse administrators do not have confidence in the patient care provided by new graduate nurses.
This lends support to the view that new graduate nurses enter the workforce with only the most
basic knowledge of nursing and that it is up to the employer to build upon that knowledge, thus
underscoring the importance of competent clinical preceptors.
Across all 36 competencies, respondents indicated that the new graduate nurses
performed poorly, even on the top-rated skills. Although there was significant variation between
the top- and bottom-rated skills, they represented broader themes of critical thinking,
communication, and professionalism. Interestingly, the skills ranked in the bottom third were
those that were better taught in clinical settings, skills such as delegation, taking initiative, and
managing multiple patient care loads.
Anderson et al. (2012) conducted a systemic review of the literature that examined the
outcomes of nurse residency programs over more than three decades, finding that residency
programs did in fact improve new graduates’ critical thinking skills. Blanzola et al. (2004) also
found new graduate nurses who participated in a residency program with a preceptor component
scored higher on basic core competencies than those who did not participate in a residency
program. Ulrich et al. (2010) compared the results of an 18-week residency program with a
control group that had an average of 17 months nursing experience. Using the Slater Nurse
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Competencies Rating Scale the new graduates demonstrated a greater or equal level of
competency rating at the end of their residency as compared to the control group.
Developing clinical skills takes observation, practice, and a basic knowledge of the issue
at hand. During orientation, preceptors can support the new graduate by seeking out
opportunities for them to perform, thus enhancing the new graduate’s acquisition of skills and
maintaining patient safety. Fink et al. (2008) found that even after one year of experience, a
number of technical skills were still identified by new nurses as problematic, including
responding to a code, providing tracheostomy care, and end of life care.
Fundamental nursing skills, such as physical assessment and documentation, need to be
evaluated when transitioning to practice in order to determine new graduate nurses’ level of
competency (Anderson, 2012; Fink et al.; Ulrich et al., 2010) New graduates need to be prepared
to function as a member of an interdisciplinary team in order to deliver safe and effective patient-
centered care (AACN, 2015b; IOM, 2010; National League for Nursing, 2015). Competency
development studies have used simulation scenarios (Aronson, Glynn, & Squires, 2013; Beyea et
al., 2007; Hagler & Wilson, 2013; Vyas, McMulloh, Dyer, Gregory, & Higbee, 2012; Waterval,
Stephan, Peczinka, & Shaw, 2012; Wunder, Glymph, Gonzalez, Gonzalez, & Groom, 2014), or
concentrated on immediate impacts (Hallin, Kiessling, Waldner, & Henriksson, 2009;
MacDonnell, Rege, Misto, Dollase, & George, 2012). Despite multiple definitions of
competency, once thing is clear: new graduate nurses need to spend time in the clinical setting, at
the patient’s bedside, gaining experience in both clinical and cognitive skills, thus increasing
their nursing knowledge. In order to do this safely, they need direct observation, via a preceptor,
and constant constructive feedback to grow as a nurse.
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Confidence Improvement
Van de Gaer, Grisay, Schulz, and Gebhardt (2012) utilized a multi-level regression model
to research the correlation between academic self-confidence and achievement. Their study
relied on data gathered from the 2006 Programme for International Student Assessment study,
and included 353,403 students from 13,886 schools in 53 countries. After analyzing the data, the
investigators concluded a positive correlation exists between students reporting higher levels of
self-confidence and schools setting high standards or expectations of them. This also held true for
the opposite, lower levels of self-confidence were reported when the expectations on students were
lower. The investigators go on to discuss “The Big Fish Little Pond” phenomenon, “Which is
related to the negative cross-national relationship between achievement and self-concept” (Van de
Gaer et al., 2012, p. 1,223). For example, students reported a higher level of self-confidence when
they received a good grade, and lower self-confidence with lower grades, and if students received
higher grades than their classmates, their level of self-confidence improved and vise-versa. Also,
students placed more emphasis on some grades as opposed to others (e.g. science), so those grades
held more sway on self-confidence reporting, both positive and negative.
An important outcome of new graduate residency programs includes positive changes in
the new nurse’s level of confidence. Confidence rises with experience and contributes to
competency. In a study using a self-rated survey completed by residents at 2, 16, and 18-weeks,
and at 1, 2, and 5-years, Ulrich et al. (2010) reported that self-confidence grew over time. After
analyzing multiple nursing residency, structured programs, and internship studies, Park and
Jones (2010) reported that new graduates demonstrated increased confidence and competence
with patient care delivery and believed that they were able to provide safe and competent care in
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the areas of assessment, critical thinking, communication, medication administration, and
technology.
The ability to employ critical thinking and reasoning in high fidelity simulated patient
scenarios suggests that the use of these simulations in new graduate residency programs can be
an important educational tool. Simulation can assist in strengthening the new graduate’s
assessment skills and competencies, thus leading to an increase in confidence. Beyea et al.
(2007) reported that the use of simulations not only promoted the new nurse’s development of
skills and competencies, but also assisted in developing nursing decision-making skills and
interventions by learning to synthesize clinical data in a safe and less stressful environment.
According to Kaddoura (2010), simulation assisted new graduates to develop important
psychomotor, cognitive, and team interaction skills by providing a safe, non-critical arena in
which to practice their skills. Kaddoura (2010) also found the use of simulations helped to
improve new graduate nurses’ collaboration and teamwork skills, leadership and delegation
skills, clinically relevant knowledge, clinical decision-making, and general clinical competency.
These findings come as no surprise, however, given that Anderson, Linden, Allen, and Gibbs
(2009) had earlier reported that high fidelity simulations promoted critical thinking and team
building in residents.
Socialization/Communication Improvement
Professional socialization has been described as a “dynamic, interactive process through
which attitudes, knowledge, skills, values, norms behaviors of the nursing profession are
internalized and a professional identity is developed” (Dinmohammadi et al., 2013, p. 32). The
ability to communicate clearly and effectively is a necessary skill for all professions, not just
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nursing. Physicians must be able to successfully communicate to their patients in order for them
to receive optimal care (Kripalani, et al., 2007).
New graduates must learn socialization skills not only to communicate effectively with
their patients, but family members and fellow staff as well. Socialization also assists the new
graduate to learn their role and the values within the organization (Dinmohammadi et al., 2014;
Lai & Lim, 2012; Price, 2009). The process of socialization involves learning the norms of the
organizational culture and redefining one’s self-concept or identity. Through this process, new
graduates are able to adapt to their roles and accept the differences in their idealistic and realistic
expectations of the profession (Zarshenas, Shariff, Molazem, Khayyer, & Ebadi, 2014).
In measuring a range of clinical competencies, Kowalski and Cross (2010) reported that a
residency program that focused on communication and leadership skills assisted new graduates
in attaining their professional goals. To assist in developing such skills, the investigators used an
educational module focused on developing communication skills among staff members and
patients. Prior knowledge and experience in using the communication techniques contributed
toward participants’ communication skill development (Kowalski & Cross, 2010). In another
study, Hickey (2009) found that 62 preceptors (out of 200 surveyed) indicated new graduates
were effective in their communication with patients, with 63% indicating that they were effective
most of the time or always with respect to their use of the communication skills they had been
taught.
The benefits of acquiring effective communication skills appear to be far reaching.
Goode et al. (2009) demonstrated that new nurses felt more comfortable communicating with
other members of the care team, patients, and families after having completed a yearlong
competency program. However, one might reasonably question whether this greater sense of
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communication confidence was a product of the program itself or of particular components of the
program. Altier and Kresk (2006), for example, found communication and constructive
feedback from the preceptors and educators helped the new graduate nurses develop mutually
respectful relationships with other members of the healthcare team and to expand their skills in
the nurturing environment.
Moreover, in a study by Komaratat and Oumtanee (2009), nursing interns reported
having developed better relationships with their coworkers and patients, as well as having
improved their communication skills because of the assistance they received from their
preceptors. Herdrich and Lindsay (2006) reported that participants of a nursing graduate
residency program not only improved in terms of their communication with other practitioners,
but that the communication skills taught during the program enhanced the nursing graduates’
socialization into their organizational relationships. These findings reinforce the importance of
new nurses mastering the art of communication, which can be accomplished through a new
graduate residency program.
Reality Shock
Reality shock can occur when a new employee’s expectations differ significantly from
what the employee experiences upon entering the organization (Dean, 1983; Kramer, 1985), such
as the professional acculturation from nursing student to nursing professional (Martin & Wilson,
2011). Kramer (1974) first discussed reality shock as a way of describing the detachment new
graduates experience between what they thought their new role would be versus the reality of the
role in the professional workplace. Kramer’s theory focused on the socialization of new nurse
graduates and described four stages that the new graduates encounter as they transition into their
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professional nursing roles. These stages were named the honeymoon, shock, recovery, and
resolution stages.
The authors of a 2011 report followed 468 new graduates in 20 Magnet hospitals within
the United States through their first year of transition into practice, specifically looking at the
impact healthy work environments play in reducing reality shock. Data was collected using the
Essentials of Magnetism II questionnaire, completed by the new graduates at 4, 8, and 12-months
post-hire. A healthy work environment was the single most significant variable affecting the
new graduates’ transition into practice. As the preceptor models used among the 20 hospitals
involved in this study had not been standardized, the new graduates’ experiences with preceptors
were not discussed in any detail (Kramer, Maguire, & Brewer 2011).
Sin, Kwon, and Kim (2014) analyzed self-report questionnaire data from 26 new
graduates in Korea on factors influencing reality shock. Making improvements in the work
environment, allowing new graduates to request days off, and self-scheduling were all
contributing factors that would assist to lessen reality shock for these nurses. Two other studies
(Cantrell, Browne, & Lupinacci, 2005; Starr & Conley, 2006) give support to the use of
residency programs as a transitional tool to assist in lessening the effects of new graduates’
reality shock.
Newton and McKenna (2007) utilized focus groups in their qualitative study, exploring
how new graduates developed nursing skills and to identify any facilitating or hindering factors.
Twenty-six nurses from Victoria, Australia, participated in the study. The authors concluded that
despite efforts by nursing schools, they could do little to reduce the effect of reality shock for
new graduates as they entered the workforce. A later study by Hinton & Chirgwin (2010) of
Indigenous Australian nurses between 2006 and 2008 (a specific number was not reported)
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reported that a nursing curriculum focusing on incorporating maximum clinical practice hours
provided a solution to reducing much of the reality shock experienced by new graduate nurses.
Burnout
Burnout, characterized by emotional exhaustion, is discussed in the literature pertaining
to job satisfaction and may contribute to an individual’s intention to leave an organization, and
lead to emotional exhaustion, frustration, and fatigue (Kristensen, Borritz, Villadsen, &
Christensen, 2005; Spence Laschinger, Grau, Finegan, & Wilk, 2010; Talas, Semra, & Selma,
2011). These same emotions have been reported among new graduate nurses in hospital settings
(Spence Laschinger et al., 2010).
Burnout has long been studied among the nursing population. Gandi, Wai, Karick, and
Dagona (2011) define burnout as:
Sustained response to the chronic work stress comprised of three components: the
experience of being emotionally exhausted, negative feelings and attitudes towards the
recipients of the service (depersonalization), and feelings of low accomplishment and/or
professional failure (lack of personal accomplishment). Burnout is a prolonged response
to chronic emotional and interpersonal stressors that an employee encounters in the
context of a job. (p. 183)
Burnout can also be defined as a syndrome comprising two core aspects: exhaustion and
disengagement (Beckstead, 2002; Leiter & Maslach, 2009; Rudman & Gustavsson, 2011).
Poghosyan, Clarke, Finlayson, and Aiken (2010) reported that burnout was on the rise across six
countries and negatively affected patient care.
The social climate of the workplace also contributes to burnout. An incongruity between
the employee’s expectations and the extent to which the workplace is meeting these expectations
52
creates a disconnect that can initiate the burnout process. Examples of expectations include
workload, control, reward, fairness, values, and social support within the workplace (Fearson &
Nicol, 2011). Garrett and McDaniel (2001) sought to explain the correlation between burnout
and social climate, finding that the social climate affected the behavior, feelings, and growth of
nurses. The social climate may also affect the individual’s morale, sense of well-being,
aspirations of growth, self-understanding, and impulse control. The investigators stated that
coping could be negatively affected by perceptions about social climate, leading to emotional
withdrawal and burnout. Once a nurse becomes withdrawn and dissatisfied with their work
environment, their intention to leave skyrockets and is directly related to cynicism, a component
of burnout (Leiter & Maslach, 2009).
Kristensen et al. (2005) conducted a survey of 1,914 employees, including nurses, across
seven workplaces to determine changes in burnout perceptions. The investigators utilized
Spearman rank correlation and regression analysis to analyze their data, finding that reported
levels of burnout changed substantially over time. Subjects reported both physical and emotional
exhaustion in the workplace. Other issues reported by participants included sleep related issues
(25%) and the weekly use of painkillers (26%). The Burnout Assessment Tool, developed by the
investigators, has been used in multiple studies to assess burnout as a general concept.
Regardless of the place of employment, younger nurses suffer from a higher rate of
burnout then their older counterparts (Gillespie & Melby, 2003; Ilhan et al., 2007). Younger
nurses face an initial shock when confronted with the realities of the job (Ilhan et al., 2007), and
lack adequate coping mechanisms due to their young age and lack of experience (Spence
Laschinger, Wilk, Cho, & Greco, 2009), resulting in 66% of new graduates experiencing
symptoms of burnout in one particular study (Cho, Lashinger, & Wong, 2006). The transition
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from student to professional has been linked with decreased confidence and low self-esteem
(Smith, Andrusyszyn, & Spence Laschinger, 2010). Role stress also has been linked with
burnout due to a lack of clear and consistent information about the role and conflicting
expectations (Chang, Hancock, Johnson, Daly, & Jackson, 2005; Rella et al., 2008) along with
lack of support and work overload (Chang & Hancock, 2003). Due to differences in age and
experience, new graduate nurses can be anticipated to experience increased burnout and have
different needs than more experienced nurses.
Depersonalization is another symptom of burnout. The characteristics of
depersonalization include distancing oneself or withdrawing from a stressful situation as a
coping mechanism (Kristensen et al., 2005; Faller & Gates, 2011). By distancing, the nurse still
delivers care, but they do not engage with the emotional aspects of caring for the patient (Pich,
Hazelton, Suden, & Kable, 2010). By utilizing depersonalization as a coping mechanism, the
nurse eventually becomes burned-out and leaves the organization (Faller & Gates, 2011).
Rudman and Gustavsson (2011) studied burnout trajectories among new graduate nurses and
found that during the first three years of practice, every fifth nurse was suffering from burn out.
Burnout develops due to prolonged, stressful situations in the workplace. Stressful events
for a new nurse may differ greatly from what more experienced nurses describe as taxing. The
latter precisely describes the reason why the new graduate nurse population desperately needs to
be examined in a different light. With the increased complexity of care and ongoing changes in
health care, burnout will continue to increase if major interventions are not implemented.
Experienced nurses who experience burnout themselves, undoubtedly, contribute to the burnout
of new graduate nurses, resulting in a negative continuum (Rudman & Gustavsson, 2011).
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The topic of burnout among new graduate nurses has not gained interest until recently,
therefore researchers are still investigating the factors that contribute to burnout. Rudman and
Gustavsson (2012) examined correlations among nursing students through their first three years
of practice. The researchers found that burnout increased from 30% to 41% across three years.
Emotional exhaustion was prevalent due to feeling unprepared when asked to use their nursing
skills, and frustration due to the lack of research utilization (using evidence-based practices
learned in school) during the first year of practice. These feelings continued throughout the first
three years of practice and were most intense during the second year and led to increased
intentions to leave the profession all together (Rudman & Gustavsson, 2011).
Summary
As seen in the literature, it is vitally important to understand the issues new graduate
nurses face as they make the transition from academic to professional roles in order to keep
retention high. A wide variety of studies, utilizing various methodologies and research styles that
have examined the needs of the new graduate, with an emphasis on formal residency programs
and preceptorships have been conducted. The literature reveals that structured new graduate
residency programs and preceptor-based teaching approaches demonstrate improved self and/or
preceptor/manager reported competency, critical thinking, and clinical skill acquisition among
new graduate nurses. The literature suggests that an effective preceptorship program is a vital
component of new graduates’ orientation process; consequently, implementing similar preceptor
training programs is highly recommended. Such measures would not only benefit the new
graduate, but also prove to be a cost saving measure for the hospital with respect to staff
retention, and most importantly, lead to improvements in the quality of patient care and safety.
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Chapter Three: Research Design
Chapter three introduces the research design and rational for the use of phenomenology.
This chapter provides a basic overview of phenomenology and phenomenological approaches to
data collection and analysis. Some of the main theorists contributing to the development of this
research paradigm will also be discussed. Examples of phenomenological research will be
offered in relation to new nurses as they make the transition from academia to the professional
field in regards to their experience with preceptors. This chapter also includes a discussion of
the research participants, including recruitment and access; data collection and storage; data
analysis and coding approaches; and the steps taken to insure the trustworthiness of the study.
This phenomenological qualitative research study explored and evaluated new graduate
registered nurses’ lived experiences with preceptors during the orientation period of a new
graduate nurse residency program. This was achieved by isolating the actions and behaviors of
preceptors through verbal descriptions and perceptions offered by the new graduates. From this,
the traits and techniques utilized by highly effective preceptors when instructing new graduate
nurses were identified. As stated in the first chapter, the following question was used to guide
this study: How do new graduate registered nurses’ describe their experiences with preceptors
during the course of the new graduate nurse residency program?
Research Design
The qualitative method of phenomenology was chosen because it allows for rich and
detailed descriptions of the subjects’ lived experiences, as told from their perspectives.
According to Creswell (2013), the phenomenological researcher identifies the themes that
emerge from the data to better understand the specific issues the population under scrutiny is
experiencing. Polit and Beck (2008) described the goal of phenomenology was to depict the
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meaning of individuals’ life experiences. Additionally, the phenomenological method can be
used as the basis for developing practical theory, as well as supporting or challenging current
policy (Ogiri Itotenaan, Samy, & Brampton, 2014).
Fitzpatrick and Wallace (2006) described phenomenology as both a research method
and philosophical movement, with meaning bridging the relationship between the individual
and the world in which they live. One of the main principles of phenomenology is the concept
of intentionality, that humans are inseparably connected to the world in which they live
(Dowling, 2005). Phenomenology attempts to aggregate individuals’ experiences with a
phenomenon into a collective essence that describes the nature of the experience (Creswell,
2013). Phenomenology helps the researcher to begin to understand what it means for the
participant to have a particular experience (Creswell, 2013; Polit & Beck, 2008).
Research Tradition
Edmund Husserl (1859–1938), mathematician and philosopher, is considered the
founding father of phenomenological research (Smith, 2007). The word phenomenon is
derived from the Greek phaenesthai, which means “to show itself” or “to appear” (Moustakas,
1994). Husserl studied the ways in which individuals interpreted their experiences through
their senses and processed these interpretations into their daily life. Husserl focused on the
individual sense-making process to gain a better understanding of the meaning of the
experience. Husserl’s student, Martin Heidegger (1889–1976), took a different approach and
focused on how the individual interprets events (i.e., modes of being) and the various
meanings attributed to interactions with the world (Laverty, 2003). Assuming existential
autonomy, Heidegger explored the individual’s lived experience, arguing that this should take
precedence over understanding the world because the lived experience actually existed (Porter
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& Robinson, 2011). Husserl and Heidegger looked at focusing on the perceptions of
participants, trying to gain a better understanding of their interpretation of the subject matter.
From there, phenomenology expanded and branched off into different methods of data
collection, including descriptive, interpretative, and hermeneutic, as researchers and
philosophers tried to gain a better understanding of the individual and how they interpreted the
world around them.
Jean-Paul Sartre (1905–1980) and Maurice Merleau-Ponty (1908–1961) followed
closely with their definitions and thoughts on phenomenology. Sartre proposed that
consciousness involved being aware of objects and that just being there was the root of
phenomenology (Laverty, 2003). Borrowing from the field of psychology, Merleau-Ponty
further defined the emergent field of phenomenology by incorporating ideas about how the
individual’s own body and its significance in our activities affects experiences in the moment
(van Manen, 2014). Despite slight variations in themes, these early pioneers based their
practice on the idea of knowledge and consciousness, on what the individual experienced, and
how the individual processed and expressed that experience.
The phenomenology of van Manen. The aim of phenomenological research is to
establish a rekindled connection with the original experience and to transform the lived
experience into a textual representation. Thus, van Manen’s (1990) hermeneutic
phenomenological approach, which is a blend of Husserl’s descriptive and Heidegger’s
interpretive traditions (Cohen & Omery, 1994; Dowling, 2005), was used in this study to
answer the research question. This approach enabled a greater understanding of the actual
lived experiences of the participants. The lived experience, according to van Manen (1990), is
the alpha and the omega of phenomenological research, and can only be reflected on as past
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experiences due to their chronological characteristics. Scholarship, according to van Manen, is
a fundamental element of human science research. Scholarship is at the heart of
phenomenology because no universally agreed upon method of conducting phenomenological
research exists, it must be explored and found.
Van Manen’s work is particularly useful as a framework for this research because the
meanings and experiences are unique to the individual participants. Van Manen’s approach is
intended to give structure to inquisitiveness. According to van Manen (1990),
phenomenological research is “the study of essences; and the description of the experiential
meanings as we live them” (p. 9). Van Manen described the lived experience as being
reflective of past presence, positing that the lived experience can never be grasped in its
immediate manifestation. In simpler terms, our experiences of the present are the sum of our
recollection of past experiences, which invariably have some degree of temporal disparity
between experience and processing. Phenomenology is well suited to the exploration of the
new graduates’ experiences with preceptors and describing how these experiences are
interpreted, understood, contextualized, and applied in practice. Phenomenological inquiry
supports the acquisition of new knowledge and developing an understanding of the lived
transitions experienced by new nurses (Creswell, 2013). Participants in this study were asked
to reflect upon and describe their experiences through the medium of the spoken word, via a
semi-structured open-ended audiotaped interview, the results of which were transcribed and
coded.
The new graduates’ experiences and their significances were identified within the
analysis of the transcripts. Through interpretation and deeper analysis of the transcripts the
essence of the phenomenon, or what is known as phenomenological text, was identified.
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Phenomenological text, as described by van Manen (1990), is descriptive in the sense it names
something, “and in the naming it points to and lets something show itself” (p. 26).
Application to research. Nursing is concerned with helping patients heal and this is
achieved, in part, through the skills in understanding one’s patients, being insightful, and
empathizing with them. Nursing recognizes the validity and uniqueness of individuals’
experiences and supports them in exercising control over their own health care (Erickson,
Tomlin, & Swain, 2008; Roy & Andrews, 2008). Phenomenology, like nursing, considers the
person as a whole, including their experiences. Nurses are taught to respect individuals, to
listen to them and believe them, to be good listeners, and to empathize and to create rapport,
often in a short period of time. These valuable skills make nurses excellent participants for
researchers conducting phenomenology studies, as they are trained to observe both the
objective and the subjective, and to use these observations to make informed decisions.
Colleen-Delany (2003) conducted a phenomenological study of ten new graduate
nurses to better understand the lived experiences of the participants in relation to their
orientation process. Using audiotaped interviews, the participants disclosed the skills of the
preceptor, both technical and nontechnical, significantly affected their perceptions and
progress through the orientation process. The new graduates also mentioned support groups,
supportive mentors and managers as well as journaling provided additional support. The most
surprising finding of the study was the unpreparedness of the new graduates for death and
dying. This study was limited, as most phenomenological studies are, as it was only ten new
graduates at one hospital, and the specificity of the results makes replication of the outcomes
difficult.
Zinsmeister & Schafer, 2009, conducted a phenomenological study with nine new
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graduates and found that providing a positive work environment played a key role in
maintaining the professional commitment of these nurses. The researchers identified five
themes that assisted the new graduates’ transition experience, including: (a) the need for a
supportive work environment; (b) participating in a comprehensive orientation process; (c)
providing a positive preceptor experience; (d) modeling a sense of professionalism; and (e)
providing clarity in role expectations. By gaining insight into the transition period of graduate
nurses, health care organizations can develop strategies to support the entire nursing
workforce.
The tradition of phenomenology, and specifically van Manen’s work, is particularly
useful as a framework for this research because the meanings and experiences are unique to the
individual participants. By taking this approach, this study is based on a paradigm of personal
knowledge and subjectivity, thus emphasizing the importance of the participants’ personal
perspectives and interpretations of the event. These perspectives and interpretations are an
essential element for the researcher, as they assist in understanding and gaining insight into the
participant’s experience. By doing so the researcher can challenge normative assumptions that
may exist pertaining to the experience, and bring to the surface issues that may not be
discovered through other research methods. This study utilized phenomenology to assist in
discovering the experiences new graduate registered nurses had with their preceptors. The
results can assist future preceptors when training new graduates, confirm the benefits of the
nurse residency program, help retain competent nurses within the profession, and most
importantly, improve patient safety.
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The Participants
This study used a purposive sampling method, which means the researcher selected
cases most likely to benefit the study (Polit & Beck, 2008). A homogenous sampling strategy
was used to limit variation and focus the inquiry on the phenomenon being studied (Polit &
Beck, 2008). The guiding principle of sample size is that participants must have experienced
the phenomenon and must be able to articulate their experience (Polit & Beck, 2008). The
sampling method selected new graduate nurses who had completed working with a preceptor
during the new graduate nurse orientation program, since this was the phenomenon of interest.
The participants in this study were new graduate registered nurses employed by Salem
Health and who met the criteria of having successfully completed the preceptor portion of the
new graduate residency program at Salem Health between February 2015 and November 2015.
Candidates were also required for inclusion to have 6-14 months of independent work
experience by the time of the interviews. Participants were considered to be new graduates if
they graduated from an accredited nursing school within 12 months prior to employment.
There was no exclusion based on the school the participants graduated from, or if it was from a
two-year (associate’s degree) or four-year (bachelor’s degree) program.
Participants were excluded if they were not enrolled in the new graduate orientation
program during the above mentioned dates, such as nurses hired at Salem Health who came
with experience from another hospital, yet still worked with a preceptor during an orientation
period. Other exclusions included nurses who transferred from one unit to another and
required working with a preceptor for orientation purposes, and nurses who were hired by the
hospital from a different health care setting, such as home health or a medical clinic, who also
required orientation with a preceptor.
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Table 3 Demographic Make-up of Participants Participants Age Gender Ethnicity Education Level
P1 24 F Caucasian BSN P2 25 F Caucasian ADN P3 23 F Caucasian BSN P4 35 F Caucasian ADN P5 26 F Caucasian BSN P6 27 M Caucasian BSN P7 25 F Caucasian BSN P8 31 F Caucasian BSN P9 28 F Caucasian BSN P10 26 F Caucasian BSN
Recruitment and Access
Northeastern University and Salem Health’s institutional review board gave their prior
approval for this study (Appendixes A and B). The researcher developed a questionnaire for
the collection of initial demographic data and an interview guide that was used in this study
(Appendix C). Volunteer participants gave verbal consent to being part of the research study
after reviewing the nature, the procedure, the risks and benefits, and confidentiality aspects of
the study with the researcher and before the audiotaped interview.
A general e-mail asking for volunteers for this study was sent to 123 individuals who
met the above criteria. Using records kept by the Salem Health Clinical Education
Department, who oversee the new graduate residency program, a list of potential participants
was generated. Twenty-seven individuals responded to the general e-mail, with nine declining
to be interviewed, and eighteen who volunteered for this research project. These eighteen
people were assigned a number-coded identity, which was entered into an Excel spreadsheet.
By using the randomization function, a sample of ten participants was selected with two
alternates.
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Data Collection
According to Creswell (2013), the semi-structured interview is the most appropriate data
collection method to achieve data validity and reliability. The interview includes direct
contact between the researcher and the participants and is a commonly accepted research
protocol to generate abundant data from the transcribed responses (Denscomb, 2014; DiCicco-
Bloom & Crabtree, 2006; McLellan, MacQueen, & Neidig, 2003; Turner, 2010). A semi-
structured interview is appropriate for data collection in this study because it elicits responses
that are representative of an interpretive relationship between the phenomenon and the
experiences of the new graduate nurses (Denscomb, 2014; McLellan et al., 2003).
Questions developed for the semi-structured interview were guided by the research
question, which elicited detailed descriptions of the new graduates’ experiences with their
preceptor. Semi-structured interviews gave the researcher more flexibility to expand upon the
pre-established questions, guiding the participants to provide richer and more descriptive
details (Creswell, 2013; Denscomb, 2014; Rubin & Rubin, 2012).
Prior to the study, the questions were piloted with two registered nurses at Salem
Health, who had completed the new graduate residency program and had been working on
their own for two years. A list of those nurses who met this criterion was generated from the
Clinical Education Department. A general email was sent out to 82 nurses asking for
volunteers. Sixteen responded and their names were entered into an Excel spreadsheet. By
using the randomization function, two nurses were selected and one alternate. The two
selected nurses agreed to participate in an informal interview in order for the researcher to
make any adjustments needed to the interview questions.
The participants were asked to participate in one 60-90 minute audiotaped interview
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with the researcher. Thirty minutes were set aside before the interview for discussion of the
nature and purpose of the project, for the participant to give verbal consent, and for the
researcher to answer any questions the participant might have about the study. The interviews
were conducted between June 30, 2016 and July 30, 2016.
Six of the interviews were conducted at Chemeketa Community College’s library in a
private room and four were conducted at Salem, Oregon’s public library, also in a private room.
The interviews were not conducted at the researcher’s office or on Salem Health property to
avoid any appearance of coercion. The interviews were conducted during participants’ non-
working hours from Salem Health. The interviews were audiotaped on the researcher’s
password-protected laptop using the QuickTime 10 player application. A test of the application
was conducted before each interview and the researcher, in case of application failure, took
written notes. Notes were also used to assist in capturing the reflection and tone of the
participants (Rubin & Rubin, 2012).
Each interview lasted 45–90 minutes, depending upon the amount of information the
participant wished to share and if any clarifying questions were asked. Each interview was then
transcribed into a Word document, printed, and reviewed within 72 hours. By continually
reviewing each transcript, referring back to the research question, and understanding the
participants’ words through exhaustive descriptions, rich details about the new graduates’
clinical experiences and answers to the guiding interview questions evolved (Miles, Huberman,
& Saldaña, 2014; Richards, 2015; Saldaña, 2013).
Creswell (2013) recommended participants be given the opportunity to review and
discuss the findings from their own data to regulate the accuracy of the findings. The
participants were contacted via e-mail directly within 24 hours after the transcriptions were
65
completed to see if they wanted to make any modifications to their transcripts. Thus, the
participants were allowed to review the accuracy of their interview transcripts with the
researcher. This allowed the participant to clarify any questions they might have or make any
revisions to their transcripts to more accurately reflect their responses. Four of the ten made
minor corrections to their transcripts by adding clarifying comments, which did not change the
meaning of the descriptive text. One did not respond to the e-mail, while the other five did not
have any changes to make.
Data Storage
Transcribed data, as well as hand-written notes, were kept in a binder separated by the
pre-assigned numerical identifier to aid in organization prior to analysis. The identities of the
participants were only stored based on their numerical identifier rather than their names to
protect participant anonymity. These files were kept on a separate Excel spreadsheet on a
password-protected computer in the researcher’s home office. These pseudonyms were used on
the audiotapes and transcriptions, thus no participant identifiers were used. Prior to coding, the
audiotapes were kept on the researcher’s password-protected computer, which only the
researcher had access, and all printed data was secured in a locked cabinet in the researcher’s
home office. After coding, the audiotapes were erased and all printed transcripts and
handwritten notes were shredded. To also assist in the protection of participant’s
confidentiality, all email correspondence between the participants and the researcher was
deleted at the conclusion of the study.
Data Analysis
Data collection and analysis are simultaneous activities in qualitative research, which
leads to the refinement of the questions and results in deeper responses (Flick, 2014). The
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interview questions were designed to explore the perceptions of the new nurse graduates’ clinical
preceptorship experiences. Van Manen’s (1990) approach was used to uncover themes and sub-
themes in the participants’ interviews. Van Manen proposed three techniques to uncover
phenomenological themes. The first approach is to evaluate the interview as a whole, identify
the overall meaning of the interview, and reduce it to one sentence. Also known as the
sententious approach, the researcher attempts to summarize the entire interview in a sentence.
The second approach proposed by van Manen (1990) is the selective or highlighting approach.
With this approach, the researcher attempts to identify particular sentences in the interview
transcript that illuminate the nature of the experience. The third approach involves a detailed
line-by-line analysis of the entire interview, each word being scrutinized for recurring themes
and ideas.
Once the themes are uncovered, they need to be isolated and broken down into
subsequent sub-themes. Van Manen (1997) maintained that themes could be isolated in several
ways. The first way of isolating themes, the detailed reading approach, has the researcher
asking, “What does this sentence, or sentence cluster, reveal about the phenomenon or
experience being described?” By reading and re-reading the transcripts, and identifying key
words, phrases, or concepts that appear in particular sentences or groups of sentences, the
researcher can then cluster these together as part of the first method of analysis.
The second stage of analysis, which asks what is essential or revealed in the text, is the
selective approach. Here the researcher discovers which statements were most revealing about
the phenomenon in question. These statements were then highlighted, grouped in clusters, and
tabulated. Finally, the holistic approach, which asks what phrases or one sentence captures the
meaning of the text, was employed a number of times. It involved stepping back and looking at
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the text again as a whole, asking which notable phrase(s) captures the fundamental meaning of
the text?
Using van Manen’s approaches as discussed above, the researcher organized the data by
first conducting open coding, by collecting significant statements from the transcripts and
grouping them into larger units or themes. The researcher was able to begin identifying patterns
and themes by further grouping textual and structural descriptions of the participants’
experiences, along with writing composite descriptions to convey the overall essence of ‘what’
and ‘how’ the participants experienced the phenomenon. All transcripts were examined for
patterns and themes derived from the lived experiences of the new graduate’s nurse/preceptor
relationship, such as commonly used phrases, quotes, or concepts to ensure that themes were
identified, noted, and reflected the essence of the new graduates’ tone, ideas, and meaning of
their preceptor experiences (Miles, Huberman, & Saldaña, 2014; Richards, 2015; Saldaña, 2013).
The data was subsequently reorganized into new categories and recoded utilizing the
concept of axial coding, identifying a core category and related categories (Saldaña, 2013). The
process of identifying similar categories was repeated with each of the ten interview transcripts.
Common key words and concepts identified between the transcripts were then grouped together.
Common descriptive words were integrated into these new categories. To ensure that the themes
did not overlap, the meaning of each theme was clarified through the use of new graduate quotes,
phrases, and common descriptive words. These words were integrated into new themes, and then
reduced further into five main themes, which still provided a rich description of the participant’s
experiences.
Guided by the conceptual framework, themes consistent with Benner’s (1984) nursing
theory were discovered and were commonly described within the new graduate’s preceptorship
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clinical experience (i.e., being a novice nurse): “I know I was a new nurse walking in the door,”
“You could tell I was a newbie,” “I felt like I was starting from scratch,” “There were times I felt
I didn’t know anything,” and “There was so much to learn, I didn’t know where to start.”
Trustworthiness
The potential for researcher bias and reactivity existed throughout this study, as the
researcher had first-hand experience with the subject. The researcher was a preceptor at Salem
Health for eight years prior to the interviews and was part of the original team that developed the
new graduate nurse orientation program. The researcher addressed these potential threats to
validly in a number of ways. The researcher no longer was a preceptor at Salem Health for two
years prior to the interviews, thus the researcher had no previous contact with the participants.
The researcher also has not been actively involved with the new graduate nurse residency
program at Salem Health for three years prior to the interviews.
Trust was established between participants and the researcher, along with veracity of the
data, through triangulation, reflexivity, and prolonged engagement with the data (Creswell, 2013;
Shenton, 2004). Triangulation is a technique that facilitates data validation through cross
checking of multiple data sources (Creswell, 2013; Marshall & Rossman, 2011). In this
phenomenological study, the investigator used triangulation via data sources (van Manen, 1990)
to enhance the credibility and dependability of the research findings. Individual participants’
viewpoints and experiences were verified against each other and, ultimately, a rich picture of the
participants’ experiences were constructed. Multiple data sources were used in the study to
support the findings.
Through triangulation, the researcher combined theories, methods, and data sources to
lend credence to the subject matter under observation (Creswell, 2013). Prolonged engagement
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with the data kept the text and responses of the survey in the forefront of the researcher’s mind,
reminding the researcher of the purpose of the study (Shenton, 2004). This process included
staying focused on the research study question to order to decrease the chances of diverging
down a different path (Kawulich, 2005).
To further ground validity and trustworthiness, reflexivity was utilized as a method to
self-examine and discover the researcher’s own experiences and biases. Reflexivity emphasizes
the importance of self-awareness, the political and cultural consciousness surrounding the
research, and the realization of one’s own biases. According to van Manen (1990), a researcher
knowing too much about the phenomena being studied can pose a problem in phenomenological
studies. Van Manen (1990) recommended making explicit one’s understandings, beliefs, biases,
and assumptions instead of forgetting “what we know” (p. 47).
Reflexivity involves continuous self-questioning and self-understanding throughout the
research process (Creswell, 2013). Throughout the study, the researcher took his own awareness,
assumptions, biases, and reflections into account by keeping a weekly journal that described the
authenticity of these perspectives. Reflexivity provided an opportunity for the researcher to
renew contact with his own experience of transition to support structural and thematic analysis
aspects of this sample’s transitional experiences (see Appendix E for examples of field notes).
Using van Manen’s (1997) method, the researcher maintained focus on the research
question and accurately reported the participants’ lived experiences. Lincoln and Guba (1985)
defined trustworthy research as having truth, value, consistency, applicability and neutrality. To
achieve trustworthiness, the researcher read and re-read every transcript multiple times to
identify consistent and applicable themes that revealed the truth of the participants’ lived
experiences. Prolonged engagement with the text invokes trustworthiness and validity and
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allows the essence of the participant’s experiences to come out. After multiple readings, the
verbatim texts were copied into a Microsoft Word document, then analyzed and coded. The text
was then categorized, synthesized and further reduced into subthemes and major themes. The
results were then compared to past literature regarding the experiences of new graduate nurses’
interactions with preceptors.
Summary
This chapter gave a detailed description of the methodology used to investigate the nature
and types of issues new-graduate nurses face as they transition from an academic program into
the profession, and how the preceptor can assist in this transition. The study was guided by the
following research question: How do new graduate registered nurses’ describe their experiences
with preceptors during the orientation period of the new graduate nurse residency program?
The study utilized a qualitative, hermeneutic phenomenology research design, using van
Manen’s multi-step data analysis approach. The ten study participants were selected without
bias using both a purposeful sampling and random selection methods. Data collection was
gathered by informal, semi-structured interviews consisting of six main questions, with some
clarifying sub-questions as needed. These questions guided the participants to reflect on their
experiences with preceptors.
The researcher utilized multiple strategies to guarantee trustworthiness and validity.
These included triangulation, reflexivity, and prolonged engagement with the data. The
researcher was also aware of the potential for researcher bias and reactivity. By identifying and
addressing these potential threats to the study, these issues were kept at a minimum and did not
bias the research. The following chapter presents the findings that emerged from the semi-
structured interviews.
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Chapter Four: Results and Findings
This chapter introduces the findings that emerged from data collection as described in the
previous chapter. The purpose of this phenomenological qualitative research study was to
explore and evaluate new graduate registered nurses’ lived experiences with preceptors during
the orientation period of a new graduate nurse residency program. Van Manen’s hermeneutic
phenomenological method was used to describe and interpret the nurses’ experiences in an
attempt to identify themes and assign meaning to the themes. The study was guided by the
following research question: How do new graduate registered nurses’ describe their experiences
with preceptors during the course of the new graduate nurse residency program?
This chapter describes and discusses the research results and findings. The results
provided insight to the central research question and provided further understanding of new
graduate nurses’ perspectives of their preceptorship clinical experiences. Findings were
supported by sound examples from the data generated by the sample.
From the axial cycles of coding five themes emerged from the data and the meaning of
each theme was clarified through use of participants’ quotes and phrases. Common descriptive
words were further integrated into the five themes to ensure no overlap. These themes include:
communication/trust; manager support, confidence improvement; role model/socialization; and
developing technical skills. Each of the five themes is discussed in detail in the following
sections.
Emergent Themes
Theme One: Communication and Trust
The foremost theme was the importance of communication and trust between the new
graduate and the preceptor. All of the participants described or identified this as the most
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significant component of the whole preceptorship clinical experience. The theme
communication and trust is defined for the purpose of this study as interactions between the
new graduate and the preceptor established within the clinical setting. This interactive
experience between the new graduate nurse and the preceptor may promote variable degrees of
bonding, reliance, and empathy.
During the interviews, “open communication” was discussed by all ten of the
participants. When asked to explain or described further Participants 1 and 9 talked about
being able to “discuss all sorts of things” and “review the day and how it as going to look.” as
well as “what complications the patients could have.” Participants 2, 7, and 10 discussed how
“open communication” assisted them to “get through the day” in a “more relaxed” manner and
to have a more “positive experience.” Participants 4, 5, and 8 reflected on the “positive
communication” between themselves and their preceptor, as they felt “safe” in going to their
preceptor with “questions” and “concerns” about their patients. Participants 3 and 6
commented on feeling “secure” in knowing they could “discuss anything” with their preceptor,
and being able to “reflect” on the days assignment. This communication between the new
graduate and the preceptor is a vital part of learning as it assists the new graduate in developing
self-confidence, building trust between the new graduate and the preceptor, and leads to better
patient care.
The preceptor-preceptee relationship was crucial during the orientation period as it was
associated with “support,” “trust,” “respect,” and “acceptance.” Participants described the base
of their relationship with their preceptor as one built on trust, with eight of the participants
using the word “trust,” “trustworthiness,” or “trusting” when further illustrating the
relationship. The participants also shared if they had not been able to trust their preceptor then
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it impacted how they trusted themselves. Participant 4 summed it up by stating, “If I couldn’t
trust her, then how could I begin to trust myself.”
Participant 1 shared that her preceptor had an “intense personality” and that she “liked
that feel of a relationship.” Participant 1 also shared that “If the trust wouldn’t have been there I
would have left.” Participant 2 stated that she and her preceptor discussed “ground rules” which
“was really helpful to establish a good start” and in doing so they “were able to work really well
together and trust each other.” Participant 3 disclosed how she felt her preceptor had an “intense
personality” and was “kind of blunt.” She went on to say this was a “Helpful challenge to me
because it made me have to be on my game all the time.”
Participant 4 shared as she is an “assertive enough person” she and her preceptor were
able to set “some boundaries” that they both agreed on, which was how “a mutual trust was
developed.” Overall Participant 4 felt that this worked “really well” during the clinical
experience.” Participant 5 stated she was “Fairly competent going in (working with a
preceptor)” as well as knew if she “got to the point where I needed help, that I really needed
help” and her preceptor would be there to “support” her. In doing so Participant 5 and her
preceptor had a “really trusting relationship that way” and “she wasn’t going to leave me high
and dry if I got to the point where I needed assistance.”
Participant 6 started off by say he and his preceptor had “a good relationship.” This was
based on the fact that Participant 6 knew his preceptor from previous clinical experience during
nursing school. Even though he had previous involvement with his preceptor he felt “as time
went on we were able to trust each other and work better together.” For Participant 6 this was
particularly helpful when he started “taking the whole group (patient assignment)” yet, his
preceptor “was there for me” when he needed assistance.
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Participant 7 described a very different experience working with her preceptor then the
first six. She discovered she and her preceptor had “very different personalities” and “could tell
from day one that it wasn’t going to work out.” She and her preceptor were able to discuss their
differences and talk to the manger about how this was not a good fit. Participant 7 was able to be
assigned a new preceptor and she described this new relationship as one that “really worked well
together and I had a great experience.” Participant 7 expressed her gratitude to her original
preceptor in that “we had a problem” and they were “able to fix it.” Now that she is working on
her own, Participant 7 stated of her original preceptor that “now we work well together on the
unit … yeah, I would say I could trust him.”
“We sat down and got to know each other before we started working,” was how
Participant 8 described her relationship with her preceptor. “It was good to get to know my
preceptor as a person” as this “helped when we had issues and had to figure out how to work
them out.” Participant 8 shared there were a “few times” when “difference of opinions” could
get “in the way,” but it “never affected patient care” and “we were always able to talk it out.”
Participant 9’s comments echoed those of Participant 8’s, in that she felt “getting to know my
preceptor right off the bat” and discovering “we were a good match” assisted in a more “trusting
and open” preceptor experience.
Participant 10 had the same experience as Participant 7, in that she did not “get along”
with her preceptor. It was not until week two that she was able to switch to a different preceptor.
She shared most of the concern was in “communication” as the preceptor “didn’t want to tell me
anything…she just wanted to do it all.” After she had a new preceptor, Participant 10 shared the
insight, “I think it would be beneficial if they (managers) maybe had a way of looking at those
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personality type things, because I think that because we were a good match, it made the
preceptorship more successful.”
One additional area the participants commented on, pertaining to communication, was
learning to communicate with physicians. Participants remarked they had difficulty in talking
with physicians, especially when the need arose to inform the physician about a patient’s
condition. Participant 3 stated she felt “unorganized” and “scared” when she needed to call the
physician. Participant 5, 7, and 9 who felt “very nervous” and “afraid” they would give the
wrong information or have the physician “yell” or “scream” at them endorsed these feelings.
Participant 6 also shared he would “start to shake” whenever he had to call the physician.
In reflecting back on their experiences all the participants who discussed concerns in
communicating with the physician stated their preceptor “helped” them develop a “script” in
order to follow when calling the physician. “This was very helpful” and “really helped reduce
my anxiety,” was how Participant 5 described working on a script with her preceptor. Participant
1 and 6 shared their preceptor had them “practice” what they were going to say before they
called and they found this “reassuring” and “less stressful” when they did make the actual call.
“I feel more confident now” and can be “an advocate for my patients” Participant 1 summarized
her experience in working with her preceptor communication.
The trusting relationships between the new graduate and preceptor were integral in all the
interviews with the participants. During the course of the interviews the participants exhibited
body language that conveyed feelings that expressed the importance of the relationship and the
experience. The researcher noted the participants posture changed when talking about their
experience. Participants sat upright and talked with livelier tones in their voice and had smiles
on their faces. Overall the preceptor role was highly regarded in the interviews with the new
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graduates. It became clear that for the majority of the participants, this relationship and the
building of communication and trust were of utmost importance as they journeyed into the new
profession.
Some participants felt they had a better experience than others, especially if there was
more than one new graduate on the unit and they could compare experiences and support each
other. The participants placed particular emphasis on “positive” and “transparent” relationships
with their preceptors during orientation. The bonds created in the preceptor-preceptee
relationships over time fostered mutual trust between the new graduate nurse and their preceptor.
Theme Two: Manager Support
The second theme, support from the unit manager, was discussed by nine of the ten
participants as being “important” and “essential” in their orientation period. Participants used
words such as “very supportive” and “made me feel welcome” to describe their respective
mangers. Participants also described their managers as having a “positive attitude,” and being
“very nice” and “receptive” towards the participants. The participants also appreciated the
managers who went “out of their way to check in on me” and to “make sure I was doing all
right.”
Participants shared their appreciation for having nurse managers available for questions
or “just to talk.” They described their managers as “awesome,” “went out of their way to make
me feel welcome,” “was always there for me,” and “she never had a bad word to say.” This
assisted in reducing the anxiety the participants were feeling as the started with preceptors. “Just
knowing someone was there who had my back took a lot of stress off,” stated Participant 1. “I
felt less stress seeing the manager on a daily basis … it made her seem more human,” shared
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Participant 6 and Participant 9 felt “more comfortable talking to her (manager) since she was
checking in with me.”
The theme “management support” is defined as caring, nurturing and advocating
behaviors from the individual managers on the units where the new graduates were working, and
for the new graduates is of substantial importance as they transition into the professional nursing
role. Participants in the study spoke of “caring” and “nurturing managers” as support systems
during their orientation time. Participant 2 shared the example of how she “had this complex
wound” and she “couldn’t even picture the things I should be using on it.” She had the idea to
shadow the wound care nurse for a day and approached her manager about it. She stated her
manager “responded favorably” to the idea, so the manager “set that up” for her and she now
feels “so much more confident now about looking at wounds and knowing what the supplies are,
and where to get them, and all that.”
Participant 3 echoed Participant 2’s comments about a “supportive manager” in “seeking
out opportunities for learning,” but wishes she could have done more. “I think that there are
more of those (opportunities) that I could have had, would’ve liked to have during that
preceptorship time, because you have a little more flexibility during that time.” Participant 3
shared she appreciated her manger “being there” and “going out of her way” to be “supportive.”
“She actually made me feel welcome and explained everything. She had been on that
unit for years, so she knew a lot,” was how Participant 4 described her manager. Her comments
reiterated Participants 2’s and 3’s comments on how the manager made her feel “comfortable.”
Participant 4 also expressed her gratitude for her manager making her feel “at ease” in asking
questions. “She (manager) told me no question is dumb, and you can ask anything,” and this
made Participant 4 feel “welcomed,” “supported,” and “part of the team.”
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Participant 5 shared her overall view of management by stating, “If you don't feel like
you’re supported (by management), you lose confidence and you lose your forward motion.”
Participant 6 shared she felt supported when her manger gave her “feedback,” both “positive”
and “constructive.” She felt this was “helpful” and “supportive” knowing that the manager was
“going to be there when you ask her to.” Participant 7 confirmed these feelings by sharing how
her manager “checked in” with her “each day” to ask how she “was doing” and to see “if there
was anything” she needed. Participant 7 also made the comment how she “appreciated her
manager” talking to her “privately” to see how she “was doing” with her preceptor. She felt this
showed “caring on the manger’s side” not only about the “new graduates on her unit,” but the
preceptors as well.
Even though Participant 9 stated she “really didn’t see” her “manager that much” she
commented that when she “needed to talk to her (manager), she was receptive and had a positive
attitude.” Participant 9 also commented she had heard from other nurse that “she was a great
manager…that she was there for her staff.” This assisted in establishing a feeling of “support”
and “trust” towards her manager. Participant 10 shared that there were “some changes in
management on the unit, so people were a bit tense.” She shared that since she had not worked
with the previous manager she “didn’t have any issues” to “commiserate” with the staff.
Participant 2 went on to say she felt the “new manager was very nice” and “went out of her way
to welcome all of us.”
Two participants had some concerns about working with their preceptors at the beginning
of the experience, but were able to go to their manager and were able to voice their concerns.
Both new graduates stated they felt the nurse manager “supported” them and “wanted them to
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succeed.” They both were able to change to a different preceptor and had a satisfying preceptor
experience.
Some of the new graduate nurses in this study described caring and nurturing behaviors
from managers, while others expressed satisfaction with the supportive roles of their managers.
All of the participants confirmed supportive managerial relationships that were especially
beneficial in times of challenging experiences or after a stressful day. For example, Participant 3
reflected on the experience she had in dealing with end of life care with her patient. She stated
she “received great support” and “additional information” she needed from her manager. This
allowed the preceptor and the nurse manager to come together and assist the new grad in
recognizing her own personal beliefs and concerns as well as in developing skills and strategies
to overcome her specific apprehensions.
The interactions of the managers and the support given to new graduate nurses may serve
as positive reinforcement. New graduate nurses who feel supported in their new roll are likely to
remain on the job. For example, Participants 1, 3, 5, and 8 commented their respective managers
were “one reason” they were not “looking elsewhere” for another position, nor “wanting to
transfer” to another “unit,” and are “happy” and satisfied” where there are due to their
“manager’s support.”
Theme Three: Developing Technical Skills
The third theme described by the participants was the continuing development of
technical skills. The promotion and development of technical skills in new graduates are often
achieved by asking questions such as why, how, and who. Fundamental nursing skills, such as
physical assessment and documentation skills need to be evaluated when transitioning to practice
to determine new graduate nurses’ level of competency. New graduates need to be prepared to
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function as a member of an interdisciplinary team in order to deliver safe and effective patient-
centered care.
Participants commented they had a “fundamental” or “basic” knowledge of skills learned
in nursing school, but being able to practice these skills and to learn additional ones was a
positive component of the preceptor experience. In working with their preceptors, participants
commented they were able to communicate with their preceptors in order to “get more time” in
“working on skills.” Participants also commented they appreciated their preceptors “found
things (skills)” for them in order to “develop skills.” Having the preceptor there to “walk
through the procedure” or to “talk it through” was also beneficial for the participant. They felt
they were “able to ask for help” if needed and were able to “develop” additional skills they “had
not learned in school.”
All the participants alluded to the importance of developing new technical skills during
the preceptor experience. Participant 1 commented, “if there was something” she “hadn’t done
before” she was able to talk to her preceptor and “watch first” or ‘talk through it outside the
room.” Participant 1 stated this was “really helpful” in ‘building my skill level” as well as
boosting her “self-confidence.” She appreciated her preceptor “being there” and “allowing the
time to review the procedure” with her. This also assisted in “building trust” between the two.
When developing her skills, Participant 2 felt she was able to talk to her preceptor about
needing “guidance” and “support.” She gave the example of her lack of knowledge in wound
care. In discussing this with her preceptor her preceptor “set some tome aside to discuss the
different dressings and such.” Participant 2 stated how in doing so she began “to feel more
comfortable” in performing this skill. Participant 5 indicated how she would have “liked more
opportunities to learn skills,” yet felt there “wasn’t really the opportunity to do so.” She shared
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how the unit she was working on was very “specific” and “limited on skills.” Learning the
“skills in class were one thing,” but not being able to “practice” them on the unit was “very
frustrating.”
Participant 6 shared how he was “frustrated” as well with “basic skills” he had learned in
school. He stated once he had “voiced” his “frustration” to his preceptor, “she found all sorts of
stuff for me to do helping out other nurses.” In doing so assisted Participant 6 in his skills
development, but he still felt as though he “was missing something.” When asked to elaborate,
Participant 6 commented he felt he was “missing the big picture” and just “running around doing
things (tasks), not really being a nurse.” Participant 7’s comments echoed those of Participant
6’s in that she felt she “really didn’t learn anything new, just reinforced the skills” she already
had experience with. She shared “it would have been nice to go to other units to see different
things” or to have a “place to go and practice skills, like we had in school.”
“Everything was rushed,” was how Participant 8 described her preceptor experience. She
felt her preceptor did not have enough “quality time” to spend with her in order to develop skills.
Participant 8 expressed how her preceptor “would do things without me” and later on “would
talk about them.” She felt “cheated” out of her experience in relation to developing new skills
and also expressed a wish “to have a skills lab” in order to “practice skills” and “develop new
ones.”
Participants 9 and 10 had the opposite experience, as they stated they “learned so much”
with their preceptor in relation to skills development. Participant 9 shared how her preceptor let
her “do everything, with her guidance at first, then on my own,” which she “really appreciated.”
Participant 9 also took the time to “seek out new opportunities” to work on her skills. Participant
10 shared how she was able to go the emergency room “to start IVs.” She went on to disclose
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how she was “appreciative” of her preceptor for “setting up” this opportunity to “develop skills.”
She made the comment how this “was a great day” in working with her preceptor.
Most of the participants believed they did not develop new technical skills or improve the
ones they did knew until they had been working with their preceptor for some time. For
example, Participant 1 said, “Watching and talking to other nurses really helped me develop my
IV skills. I guess it just takes time.” Several participants agreed that they were able to become
skilled at IV placement by observing not only their preceptor, but also other nurses in action.
Participant 2 stated, “My preceptor put the word out to other nurses I needed practice on IVs, so
the other nurses let me put them in on their patients when I was free.”
All participants stressed that they wished they had “more time” in orientation prior to
being assigned a preceptor to practice skills or that there was a place they could go to practice on
their own. A common thread among the participants was the need to continually practice their
technical skills, such as in a simulation lab, as Participant 3 said, “I was able to practice in the
med room, but it really wasn’t the same.” Developing clinical skills takes observation, practice,
and a basic knowledge of the issue at hand. During orientation, preceptors can support the new
graduate by seeking out opportunities for them to perform, thus enhancing the new graduate’s
acquisition of skills and maintaining patient safety.
Theme Four: Confidence Improvement
Confidence improvement, not only in skill development, but also in “building of self-
confidence” was the fourth theme described by the participants. Support from preceptors in the
form of “feedback,” “debriefing,” and “progressive responsibility” was noted as indicators of
establishing self-confidence. New graduates discussed having a preceptor with whom they could
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consult was highly beneficial in strengthening their skills and building their self-confidence
during and after the orientation period.
Participants used words like “preparedness,” “readiness,” and “prioritization” to describe
their development of confidence improvement. Participant 3 stated, “I thought I was ready, but
really wasn’t (to take care of patients), but my preceptor helped me though my thought process,”
while Participant 5 shared, “I struggled with prioritization…my preceptor tried to help me and I
eventually got better.” Participant 9 reflected “My preceptor helped me figure out a way who
(which patient) to see first and how to manage my time better,” and Participant 10 summed it up
by stating, “School did not prepare me for being a real nurse…my preceptor was really good…I
learned a lot of skills from her.”
The new graduates also felt supported and had the time needed to “build confidence” and
make independent, critically weighed decisions with the assistance of a preceptor. If the new
graduates received this support, then “self-confidence,” “trust,” and “respect” were fostered.
Seven of the ten participants reported a change in their self-confidence, either during or within a
few months after their preceptorship experience. Participant 1 reflected on the feedback given
by her preceptor, letting her know she could “trust her” and was “efficient, effective, and did
everything you needed to do.” Participant 1 felt this was “a good confidence builder” and gave
her the confidence to say, “Okay, I’ve got this.”
Participant 3 shared how once her preceptor “let her fly solo” she “did not like being out”
on her own, “not knowing that there wasn’t somebody walking behind” her and “double-
checking everything” she was doing. She reflected further once she “got her feet under her” she
started “feeling more like a real nurse.” Yet, she knew her preceptor would be there in case
“anything went wrong.” Participant 4’s comments reflected what Participant 3 shared in that she
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felt “worried” and “scared” about being on her own. In talking with her preceptor she reflected
on the past couple of weeks and realized she “had been on her own” and did “just great.”
Participant 4 stated she “needed that boost of self-confidence” in order to “move on” and to
begin to “feel like part of the team.” Knowing that “other nurses” were there to “help her out if
needed” also added to Participant 4’s development of self-confidence.
“I didn’t know I was ready for independent practice,” was the comment Participant 6
shared. He reflected he “had a crutch for so long” in relying on his preceptor that on his first day
on his own he felt like he “was back to square one.” When he discussed these feelings with his
preceptor she reminded him of all the “things” he “had accomplished” and that he knew “what to
do” when presented with a “situation.” Participants 6’s preceptor reminded him he “got this,”
and that he “was ready to be on his own.” These “pep talks” assisted in his development of self-
confidence” of not only a nurse, but also of a “human being.”
Two of the participants discussed how their preceptors reviewed critical thinking
questions using real clinical situations to assist in boosting their confidence level. Participant 1
said, “Yes, my preceptor did help improve my confidence by letting me know I was doing things
right and not being mean when I was wrong,” and Participant 2 commented that, “Reviewing
scenarios really helped me feel prepared to take care of patients.”
The participants’ comments lend support to the fact preceptors and managers need to be
aware new graduate nurses need extra assistance in developing their sense of self-confidence.
For example, Participant 3 said, “They (other members of the healthcare team) didn’t treat me
like an idiot if I didn’t know the answer right away.” Participant 4 said, “My preceptor helped
me develop a script to use when calling the doctor, it really helped me get over my nervousness
about calling him.” Participant 6 commented, “My preceptor made sure she introduced me to
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everyone, so I felt part of the team, ” while Participant 8 reflected, “My manager was always
talking positive and giving me pep talks, which really helped boost me self-esteem.”
All of the participants indicated that being able to discuss the potential complications that
could arise while taking care of patients with their preceptor, what to look for, and how to avoid
or correct any complications was “highly beneficial” in improving their confidence levels.
Participant 7 commented, “At first I didn’t feel my assessment skills were that good, I wasn’t
ready to start on patients,” but she felt after working with her preceptor she “was able to improve
and provide the care I wanted to.” Participant 8 stated,“ As we went on (in the orientation
period) I felt I began to see the ‘big picture’ and became more confident in problem solving,”
and Participant 9 echoed these feelings by sharing, “I definitely didn’t feel like I was ready to
start taking care of patients … my preceptor helped me to see I was.”
Preceptorship not only prepares new graduates for the realities of working in health care,
but also assists in the crucial process of building self-confidence. The opportunities for additional
hands on training provided by the preceptor or nurse manager increased the new graduate’s skill
proficiency, but also instilled, nurtured, and developed a sense of confidence in their own
abilities. The development of self-confidence lends support to a feeling of belonging, a crucial
element in the retention of new graduates in the workplace.
Theme Five: Role Model and Socialization
Theme five, role model and socialization, emerged as the participants described the
preceptor as being a “positive role model” as well being introduced to the culture of the hospital
and individual unit. This assisted the new graduate to begin to feel as “part of the team,” as
described by Participants 3, 4, 6, and 8. Two new graduates described “getting off to a rocky
start,” but once those individual issues were resolved, all participants stated they enjoyed and
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valued the preceptor experience.
The new graduates voiced the importance of making connections and feeling connected
with other members of the healthcare team as they developed their professional personas. Seven
of the participants said their preceptors provided guidance and were a positive role model. The
participants also commented on how their preceptors assisted in navigating electronic charting,
how to talk to other members of the health care team, and how to speak up for their patients.
Three participants made the comment they sometimes felt like they were being judged as a
group, not as individuals.
“The first day she (preceptor) took me around and introduced me to everyone,” was the
comment made by Participant 1. This action made her feel “like part of the team, not just a
visitor.” Participant 1 reflected this has “really been beneficial” in that she feels like a “true
member of the team” and not just “the new person.” She also reflected she “has a better report”
with “doctors” and other members of the “healthcare team.”
Participant 2 ruminated on her preceptor experience in that her preceptor “would always
help me or provide guidance, demonstrate, or just help me” when she had a question. This
assisted in building her “sense of self-worth” and “confidence.” Participant 2 noted how
everyone on the unit “looked after each other” and “supported each other.” During self-
reflection, she realized that the unit she was working on “was the place to be for me.”
Participant 3’s comments were very similar in nature as Participant 2’s as she commented her
unit “is so amazing, there’s support from everybody, not just your preceptor.” She went on to
state “this is what I thought nursing would be like…a big family.” Having other staff “look out”
for her has assisted Participant 3 to feel “at ease” working on the unit which has led her to
“making new friends” on other units in the hospital.
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Participant 4 had a different experience when it came to role modeling. She shared how
she heard her preceptor make a “negative comment” to another staff member in regards to her
abilities. She felt this was “unprofessional” and made her feel “worthless” and question if she
“had made the right choice.” She shared her feelings with other new graduates and “discovered”
other preceptors had “made the same negative comments.” Participant 4 did share her feelings in
a reflection group as part of the residency program, yet she felt she “didn’t get the support” she
needed form the nurse educator leading the group.
Participant 6 shared a similar experience in that he was “having trouble” administering
certain medications. In sharing his concerns with his preceptor, she made the comment
“everyone” was having trouble, so she “would expect him to as well.” When asked to clarify this
remark, Participant 6 felt it was said as a “derogatory comment,” and did not “reflect the true
spirit of nursing.” Participant 7 also had a negative experience in regards to role modeling. She
shared how she was “lumped into the group (of new graduates)” and not looked at “as an
individual” when working with her preceptor. She felt she had to “prove” to her preceptor she
was “different” from the other new graduates, an “individual.” Participant 7 stated that once she
had “cleared the air” she and her preceptor “got a long great.”
Participants 5 and 8 had “very positive” experiences with their preceptor in regards to
role modeling and socialization. Participant 5 stated her preceptor was “just who I want to be” in
regards to as a nurse. Her preceptor demonstrated “leadership, strength, compassion, and
humanity,” and she felt her preceptor “emulated” what a “true nurse” should be. Participant 8
shared how her preceptor challenged her to “be better” and to “learn from mistakes.” Participant
8 also reflected how not only her preceptor, but “all the staff respected each other and their
patients.”
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Most participants said their preceptors provided guidance and were a role model in
learning the professional nurse’s role and expectations. Almost all of the participants indicated
an improved ability to communicate with both patients and families as a result of their
experience with preceptors. Seven of the participants spoke of their initial difficulty in
introducing themselves to patients; they were hesitant and apprehensive because they had
minimal experience in their nursing program. For example, Participant 5 said, “I was really
nervous at first going into the patient’s room if there was family there, but I soon got over that,”
and Participant 7 said:
I am so focused on the patient and doing the right thing I sometimes would ignore
the family in the room. My preceptor would talk to them at first, but then made me talk
to them, let them know what I was doing.
Preceptors not only play an important role in the growth of the new graduate, but also in
the integration of the new graduate into the clinical setting via socialization. Each of the
participants commented on starting to feel connected with other staff, be it through
communication or interdisciplinary collaboration with patient care while working with their
preceptor. The participants also commented on the way their preceptor made them feel
comfortable in the working setting. Being able to communicate efficiently to staff and patients
assisted the participants in their personal development as a nurse as well as assisting in their
assimilation to the hospital culture.
Research Limitations
This study sought to investigate and evaluate the experiences of new graduate nurses in
their interactions with their preceptors during the course of a new graduate nurse residency
program at Salem Health, in Salem, Oregon. This study was limited by a reliance on narratives
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localized to a specific health care setting and the use of a limited sample size of ten participants.
Consequently, the transferability of the findings of this study is limited to new graduate nurses in
this hospital setting. However, the findings of this study might be generalizable to all situations
and populations with characteristics similar to those defined in this study. Another limitation of
this study was homogeneity. With only one of the participants being male, this study did not
accurately capture the male perspective of new graduate nurses, which may have been different
than their female counterparts.
The use of only one data collection method posed another limitation. Other research
methods could have increased the validity of the findings, particularly if a quantitative method
was used in conjunction with qualitative (e.g., a survey administered at set times throughout the
preceptor experience). The study was also limited by the usefulness of the results to the primary
stakeholders, Salem Health and its clinical education department, as well as future new
graduate nurses and preceptors at Salem Health.
Summary
The purpose of this qualitative, phenomenological research was to understand the lived
experiences of new graduate nurses’ interactions with preceptors by asking the question: How do
new graduate registered nurses’ describe their experiences with preceptors during the
orientation period of a new graduate nurse residency program? In this chapter, the data
collection and analysis process, as well as the five main themes that emerged from the analysis,
were presented in detail by providing examples from participants’ interviews. Clear descriptions
of the participants’ recollections of their preceptor experiences ensured that interpretation behind
the preceptors’ behavioral patterns, expressions, thoughts, values, and motivations were
understood.
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The five themes that emerged from the data and the meaning of each theme was
clarified through use of participants’ quotes and phrases, and common descriptive words were
further integrated into new themes to ensure no overlap. The foremost theme was the
importance of communication and trust between the preceptor and the new graduate. The
second theme derived from the data was the need for support from the unit manager. The third
theme described by the participants was the continuing development of technical skills.
Confidence improvement, not only in skill development, but also in communicating with
patients and staff and a building of self-confidence was the fourth theme described by the
participants. Theme five, role model and socialization, emerged as the participants described
the preceptor as being a positive role model as well being introduced to the culture of the
hospital and individual unit. The last theme that emerged through the data was the overall
positive experience the participants had with their preceptor.
In the next chapter the researcher will review and discuss the interpretation of the primary
findings in relation to the theoretical framework and literature reviewed. The topics discussed
are those first explored in the literature review of this study and include: critical thinking,
technical competency, confidence improvement, socialization and communication improvement,
reality shock, and burnout. The researcher will present recommendations based on these themes
as well as the five themes that emerged from the participants’ data. The researcher will also
discuss recommendations for further research and practice in relation to the findings and a final
conclusion will be offered.
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Chapter Five: Interpretations, Recommendations, and Conclusions
The purpose of this phenomenological qualitative research study was to explore, identify,
and evaluate new graduate registered nurses’ lived experiences in their interactions with
preceptors during the course of a new graduate nurse residency program as they make the
transition into the nursing field. To examine this issue, the following question was addressed in
this study: How do new graduate registered nurses’ describe their experiences with their
preceptors during the orientation period of the new graduate nurse residency program? This
study sought to reveal the essence and obtain a deeper understanding of the phenomenon.
Analysis of the data revealed five themes: communication and trust; manager support;
developing technical skills; confidence improvement; and role model and socialization.
In this chapter, the researcher will review and discuss the interpretation of the primary
findings in relation to themes discovered in Chapter four. These themes include: communication
and trust; manager support; developing technical skills; confidence improvement; and role model
and socialization. These themes will be addressed in detail and an overall discussion will follow
with supportive literature. A discussion of these themes and how they relate to the themes
critical thinking, technical competency, confidence improvement, socialization and
communication, reality shock, and burnout, as discussed in the literature review of Chapter two
will follow. Following this the theoretical framework, Benner’s (1984) Novice to Expert, used in
this study will be discussed.
Finally, the researcher will offer recommendations based on the data gathered from the
participants. These recommendations include providing a supportive learning environment,
additional preceptor time, scheduling, looking at the individual, matching teaching and learning
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styles, and developing technical skills. The researcher will also discuss recommendations for
further research and practice in relation to the findings and a final conclusion will be offered.
Interpretation of Primary Findings
The analysis of the interview data was guided by van Manen’s phenomenological
method, as described in Chapter three. By isolating themes derived from the interviews, the
researcher was able to discern structural meaning of the experiences these new graduate nurses
encountered. Five main themes were identified: communication and trust; manager support;
developing technical skills; confidence improvement; and role model and socialization, that
conveyed the essence of the lived experience of the ten new graduate nurses and the meaning
they acquired that continues to influence their nursing practice. After identifying the major
themes during the coding process, the participant’s transcripts and words were reviewed once
again and summarized within the five themes. It is essential new graduates acquire and maintain
a strong basis of both clinical and non-clinical skills from which to build upon. This assists the
new graduate not only in their professional progression, but contributes to positive patient
outcomes (Berkow et al., 2009; Bolden et al., 2011; Casey et al., 2004; Killam & Heerschap,
2013; Laschinger & Grau, 2012; Rudman & Gustavsson, 2011).
Literature suggests new graduates are frequently lacking in these skills and, along with
suffering from reality shock and burnout, have the potential to put themselves and their patients
at risk (Baxter, 2010; Brown, Neudorf, Poitras, & Rodger, 2007; Duchscher, 2009; Garrett &
McDaniel, 2001; Laschinger, Finegan, & Wilik, 2009; Rella, Winwood, & Lushignton, 2008).
These results from this study confirm that new nurses require consistent support and professional
development during their first year of practice. Evidence of this finding includes comments made
by participants in relation to the five themes, which are now discussed in more detail.
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Communication and Trust
Communication and trust between new graduate nurses and preceptors has been a focus
of several studies. Ulrich et al., (2012) suggested the preceptor should have knowledge of
communication and coaching strategies, be trained in adult learning theories and learning styles,
as well as possess an understanding of learner assessment and evaluation. According to Duteau
(2012), a successful preceptorship will assist in building the new graduates’ socialization and
self-confidence as well as supporting improvement in communication and technical skills. This
in turn can lead to a more positive clinical experience for the new graduate. Rodrigues and Witt
(2013) support a positive preceptorship by noting that preceptorships can improve
communication skills, promote autonomy, as well as facilitate teamwork for the new graduate.
Relationships between new graduate nurses and preceptors are vital and must be
established early on in the relationship in order to gain the necessary learning experiences. It is
through role modeling by the preceptor and open communication such relationships can develop
(Koloroutis, 2004). Some studies have recommended core curriculum for new graduate nurse
training which includes critical thinking, communication skills, prioritization, and utilizing
Benner’s (1994, 2004) Novice to Expert theory (Boyer, 2008; Lowen et al., 2011; Melillo et al.,
2012; Staffileno & Carlson, 2010). Warren and Denham’s (2010) results reinforced the findings
in the literature describing effective preceptors as ones who develop relationships with the new
graduates that indorse expressive communication, act as role models, and provide positive and
beneficial feedback to the new graduate.
Kovner et al. (2007) noted when there was a breakdown in communication between
preceptor and new graduate the confidence of the new graduate diminished, which can lead to
their inability to provide safe and quality care to patients. This breakdown can also lead to the
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new graduates’ inability to communicate accurately to physicians, patients, and other members
of the healthcare team (Kovner et al., 2007). If new graduate nurse have difficulties in
communication this can lead to negative implications for patient safety, as pertinent information
may not get passed on to physicians and other members of the healthcare team (Boswell &
Wilhoit, 2004)
Results of a descriptive study by Carlson, Pilhammar, and Wann-Hansson’s (2010)
established the professional socialization between new graduate nurses and preceptors led to
establishing a trusting relationship and assisted in enhancing the clinical experience. Preceptors
themselves find trust to be essential, especially when it comes to giving the new graduate more
responsibility (Häggman-Laitila, Elina, Riitta, Kirsi, & Leena, 2007). While an ethnographic
study conducted by Carlson et al. (2010) demonstrated that once a trustful and supportive
relationship was established, preceptors gave new graduates more independence and
responsibility, which aided in establishing a positive learning outcome for the new graduate.
The novice nurse, according to Benner (1984), has very little experience and requires
guidance; they need rules and objectives to assist them in performing their duties and caring for
patients (Tomey & Alligood, 2006). This is why it is so important for a novice nurse to have
someone, such as a preceptor, that they can trust and go to with questions (Benner, 1994).
Preceptors facilitate new graduate nurses’ learning through the development of mutual trust
during the precepting relationship. Furthermore, preceptors have expressed the importance of
creating a trusting relationship to enhance the feeling of security for the student. By doing so,
new graduate nurses reported that the preceptorship experience was enhanced (Carlson,
Pilhammar, & Wann-Hansson, 2010; Koloroutis, 2004).
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Manager Support
Today’s health care environment requires nurse managers to possess the ability and
desire to coach and mentor staff, including new graduate nurses (Shiparski, 2005). Nurse
managers must also accept the responsibility to assist new graduates by providing individual
coaching to help improve conflict management skills as well as one-on-one mentoring (Bratt,
2009; Coomber & Barriball, 2007; Twibell & St. Pierre, 2012). Cowden et al. (2011) proposed
the nurses who were employed on units where they felt supported by their managers and
coworkers, where they were acknowledged and appreciated for their contributions, and inspired
to participate in decision making were overall more satisfied with their working environment and
more committed to their place of employment.
Having a strong positive leadership presence can also create a positive role model for the
new graduate and has the potential to lead to mentorship as the new graduate progresses in their
career (Dubiel, 2013; Hicks & McCracken, 2010). The literature, as well as this study, suggests
that having the nurse manager accessible and available plays a crucial role in the development of
new graduates’ sense of confidence, especially in interprofessional collaboration (Pfaff, Baxter,
Jack, & Ploeg, 2014). The literature suggests that programs should be developed to assist nurse
managers in their interactions with new graduates, thus building stronger relationships between
the two (Cockerham, Figueroa-Altman, Eyster, Ross, & Salamy, 2011; D’Addona, Pinto, Oliver,
Turcotte & Lavoie-Tremblay, 2015).
Development of Technical Skills
New graduates come to the clinical setting from school as a novice, with a fundamental
knowledge and skills set needed to provide basic patient care (Benner, 1984, 2004). The novice
nurse focuses on achieving set goals and tasks that need to be accomplished without questioning
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or considering other priorities. Studies performed by nurse researchers have shown that working
with a preceptor has increased the effectiveness and efficiency of new graduates’ skills
performance (Boyer, 2008; Cherry & Jacob, 2011; del Bueno, 2005; Duteau, 2012; Hickey,
2009; Olson, 2009; Vance, 2000). Therefore, preceptors must seek out critical learning
experiences for new graduate nurses if they are going to develop the technical skills necessary to
function in the clinical setting.
With a shortage of nursing staff, many health care organizations are hiring new graduates
and, without a competent residency program in place to assist them, many new graduates suffer
immense stress and job burnout (Oermann & Garvin, 2002; Oermann & Moffitt-Wolf, 1997).
The development of a residency program that assists the new graduate in learning both technical
and non-technical skills is essential in supporting their transition and requires knowledgeable
preceptors (Myrick & Yonge, 2005; Yonge, Ferguson, Myrick, & Haase 2003). More than 40%
of new graduate nurses reported they felt unprepared to identify and intervene in life-threatening
complications, as well as have a higher incidence of making mediation errors O’Keeffe (2013).
Preceptors can assist new graduates in these matters as well as help them visualize and develop
the kind of technical skills they must perform in a variety of clinical settings (Richards &
Bowles, 2012).
Confidence Improvement
Preceptorship not only assists new graduates in their preparation for working in the
hospital, but also the crucial process of building self-confidence. Past studies have shown a need
for the development of residency programs to address the development of confidence within the
new graduate nurse (Duchscher, 2008; Duclos-Miller, 2011; Fero et al., 2008; Marshburn,
Engelke, & Swanson, 2009; Roth & Johnson, 2011; Ulrich et al., 2010). Preceptor experiences
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can assist new graduates with familiarizing themselves with hospital policies and empowers
them to confidently adhere to these policies once they have completed their orientation (Speers,
Strzyzewski, & Ziolkowski, 2004). Positive reinforcement can also assist in building a new
graduate’s confidence (Hodges, Keeley, & Troyan, 2008).
Confidence is essential for effective collaboration between all members of the healthcare
team. Pfaff, Baxter, Jack, and Ploeg (2014) found new graduate nurses often have a deficiency
in self-confidence that can have a negative impact on patient care and outcome. According to
Benner’s (1984) Novice to Expert theory, as nurses advance in experience they become more
proficient and confident in their knowledge, skills, and attitudes. New nurse graduates are
considered to be in the novice stage of nursing skill development, having very little experience
that assists them to recognize some aspects of situations, so they still require support and
assistance.
Nursing literature has reported that in some areas of care it can take a new graduate one-
year to obtain the competence and confidence to independently provide care for patients (Koh,
2013). Additionally, some studies that examine self-efficacy in nursing have focused on self-
reports of one’s confidence (Chesser-Smyth & Long, 2012; Marshall & Shelton, 2012; Rosen,
2000) and self-confidence appears to facilitate competence in practice (Chesser-Smyth & Long,
2012). The literature has also showed positive reinforcement from preceptors, peers, and
managers can assist in building a new graduate’s confidence, not only with patient care, but also
in terms of interacting with that patient’s family, peers, and other members of the health care
team. Bagnardi (2014) discussed the importance of developing confidence among new graduates
and how preceptors can assist with this, be it in teaching prioritization, organization, or other
“soft” skills.
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Role Model and Socialization
Building relationships is one of the focuses of nurse residency programs emphasizing
collaboration and communication among staff, managers, and administrators (Anderson et al.,
2012). As new graduates complete their residency programs they become more competent and
prepared to deal with new workplace challenges (Bratt & Felzer, 2011). Preceptors work closely
with and are role models for new graduates. Following their examples enhances confidence and
promotes team work and socialization as the new graduates become competent professionals
(Bratt & Felzer, 2011; DeSilets et al., 2013; Halfer et al., 2008).
The majority of the participants described their preceptors as “good” or “excellent” role
models who provided guidance throughout their orientation. Having preceptors emulate positive
role modeling can assist new graduates to focus on delivering quality patient care. Relationships
between new graduates and preceptors are vital and must be developed in order for the new
graduate to benefit from the learning experience. Through role modeling, guidance, and open
communication, such relationships can develop (Koloroutis, 2004).
Socialization is a way for the new graduate nurse to begin processing their values,
traditions, obligations, and responsibilities of the profession, thus starting professional identity
development (Feng & Tsai, 2012). During this socialization process, new graduate nurses are
exposed to the group culture of the workplace (Bisholt, 2012). An important dimension of this
progression is the interaction with coworkers and other members of the healthcare team. The
socialization process may, at times, impose difficulties for the individual transitioning to a new
role, thus the guidance of a preceptor is crucial during this time (Phillips, Kenny, Esterman, &
Smith, 2014).
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Socialization within the workplace may prove beneficial in the development of creative
learning environment (Newton et al., 2011). However, the provision of continued training and
support is necessary for their success and retention in the workforce. Newton et al.’s (2011)
study is in line with previous research that supports the idea of continued training and support in
the workplace (Ranse & Arbon, 2008; Casey et al., 2004). With the improvement of social
interactions of new graduate nurses within the workplace, their confidence may grow as they
gain new knowledge through different learning situations and patient experiences (Newton et al.,
2011).
Review of Themes in Relation to Literature Review
Critical Thinking
Critical thinking refers to one’s ability to be prepared to analyze and assess the issue at
the given moment; to be ready to correctly interpret, formulate, and prioritize the data at hand;
and to arrive at the best solution to the present problem (Facione, 2010; Nosich, 2012; Paul &
Elder, 2006). Results from multiple studies have shown residency programs, with a preceptor
component, have assisted in enhancing the critical thinking skills of new graduate nurses
(Anderson et al., 2012; Blanzola et al. 2004; Fink et al., 2008; Ulrich et al., 2010) as well as
receive support from professional organizations (AACN, 2015b; IOM, 2010; National League
for Nursing, 2015).
The actual phrase “critical thinking” was not discussed or articulated by participants as a
discreet topic in itself, but was interwoven within the participants’ broader dialog. Participants
used words like “preparedness,” “readiness,” and “prioritization” to describe their development
of critical thinking skills. All of the participants indicated that being able to discuss the potential
complications that could arise while taking care of patients with their preceptor, what to look for,
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and how to avoid or correct any complications was highly beneficial in developing their critical
thinking skills. Participant 3 commented, “At first I didn’t feel my assessment skills were that
good, I wasn’t ready to start on patients … with my preceptor I was able to improve and provide
the care I wanted to,” while Participant 6 shared, “As we went on (in the orientation period) I felt
I began to see the ‘big picture’ and became more confident in problem solving,” and Participant
8 reflected, “I definitely didn’t feel like I was ready to start taking care of patients … my
preceptor helped me to see I was.”
Most of the participants believed they did not learn how to prioritize until they had been
working with their preceptor for some time. For example, Participant 1 stated, “Watching and
talking to other nurses really helped me figure out my prioritization skills. I guess it just takes
time.” Overall, the participants did not feel they perfected their skills during orientation;
however, some participants did learn which situations required immediate action versus
situations that could wait. Several participants agreed that they were able to become skilled at
prioritizing by observing not only their preceptor, but also other nurses in action, noting how
they handled their patient assignments.
The majority of the participants had some problems with prioritization as new graduates.
For example, Participant 4 stated, “It’s really easy if the patient is in trouble, you go see them
first. After that, you just see who is awake and go from there.” Participants sometimes felt
overwhelmed and inadequate when challenged with clinical situations that required immediate
decisions related to priorities. Participant 7 said, “We practiced this in school (prioritization). It
is way different once you are on your own.”
Three new graduates commented that it was not until after their preceptorship, when they
were working on their own and were exposed to working with different nurses, that they had the
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opportunity to observe a variety of methods as to how nurses prioritize their workload. This
helped them learn which actions were important versus which tasks could wait. Participant 6
commented, “I really relied on the night shift (previous shift) to help me figure out who to see
first and so on.” While Participant 9 stated, “I really relied on the charge nurse or previous shift
to help me figure out who to see first. I think it just comes with time and experience.”
Major themes derived from participant transcripts align with certain aspects of the
literature including the need to develop critical thinking. Applin et al. (2011) reported a
residency program encouraged the participants to become critical thinkers, while Anderson et al.
(2012) found evidence of improved critical thinking among those who went through a residency
program. Kowalski and Cross (2010) utilized multiple measurement scales to review residency
programs with the data revealing an improvement on participant’s critical thinking skills and
Applin et al. (2011) reported a residency program supported the development of new graduate
competency, this encouraging the participants to become critical thinkers.
Technical Competency
According to While (1994), competency is the “possession of knowledge, practice skills,
attitudes, and the ability to perform to a prescribed standard” (p.526). Competency as it relates
to nursing can be further defined as the “nurse’s ability to demonstrate a set of skills and
expectations within an established period” (Good & Schulman, 2000, p. 77). These fundamental
nursing skills are important as the new graduate makes their transition to practice, as they need to
be prepared to function as a member of an interdisciplinary team in order to deliver safe and
effective patient-centered care (AACN, 2015B; Hallin et al., 2009; IOM, 2010; MacDonnell et
al., 2012).
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The use of a simulation lab (either low or high fidelity) has been shown not only to
increase nurses’ technical skills, but is an acceptable teaching method for nurses to practice and
retain their skills (Bevan, Joy, Keeley, & Brown, 2015; Bland, Topping, & Tobbell, 2014;
Moule, 2011). The comments made by participants support this part of the literature in that
preceptors, managers, and educators need to be aware new graduate nurses need extra assistance
and time in developing their technical competency skills. For example, Participant 5 specified,
“When we had general orientation we practiced some skills in the lab, it would have been nice to
have the lab open during the day so we could go and practice,” and Participant 8 disclosed,
“Having an open lab somewhere to practice, like we had in school, would have been helpful.”
These findings are consistent with Benner’s (1984) model of novice to expert, which
requires continuing support and education for new graduates to progress professionally. This
research is also consistent with Fink et al.’s (2008) findings that even after one year of
experience, new nurses identified a number of technical skills as problematic. The Nurse
Executive Center (2007) also articulated in their article the concern employers expressed about
graduate nurses’ lack of readiness to practice in the hospital setting.
Confidence Improvement
As stated earlier, working with a preceptor not only prepares new graduates for the
realities of working in health care, but also assists in the crucial process of building self-
confidence (Cowin & Hengstberger-Sims, 2006; Freiburger, 2002; Ulrich et al., 2010). Seven of
the ten participants reported improved self-confidence, either during or within a few months after
completing their preceptorship experience. The opportunities for additional hands on training
provided by the preceptor or nurse manager increased the new graduate’s skill proficiency, but
also instilled, nurtured, and developed a sense of confidence in their own abilities.
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The development of self-confidence lends support to a feeling of belonging, a crucial
element in the retention of new graduates in the workplace (Baltimore, 2004; Kelly &
McAllister, 2013; Winter-Collins & McDaniel, 2000). Two of the participants discussed how
their preceptors reviewed critical thinking questions using real clinical situations to assist in
boosting their confidence level. Participant 1, “Yes, my preceptor did help improve my
confidence by letting me know I was doing things right and not being mean when I was wrong;”
and Participant 2 expressed that, “Reviewing scenarios really helped me feel prepared to take
care of patients.”
Having a strong positive leadership presence can also create a positive role model for the
new graduate, and has the potential to lead to mentorship as the new graduate progresses in their
career (Dubiel, 2013; Hicks & McCracken, 2010). The literature, as well as this study, suggests
that having the nurse manager accessible and available plays a crucial role in the development of
new graduates’ sense of confidence, especially in interprofessional collaboration (Pfaff, et al.,
2014). The literature suggests that programs should be developed to assist nurse managers in
their interactions with new graduates, thus building stronger relationships between the two
(Cockerham, Figueroa-Altman, Eyster, Ross, & Salamy, 2011; D’Addona, et al., 2015).
Socialization and Communication Improvement
Socialization can be defined as the process of enculturation where an individual is
exposed to a new culture through different routes and practices (Beck-Jones & Perryman, 2015).
Socialization also assists the new graduate to learn their role and the values within the
organization (Dinmohammadi et al., 2014). The ability to socialize and communicate clearly and
effectively is a necessary skill for new graduates to develop and has been the topic of recent
studies (Dinmohammadi et al., 2014; Kowalski & Cross, 2010; Lai & Lim, 2012; Zarshenas et
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al., 2014). Being comfortable communicating with other members of the healthcare team,
patients, and families is an important skill for new graduates to master as it can lead to
developing relationships and improve patient outcomes via patient education (Goode et al., 2009;
Herdrich & Lindsay, 2006; Komaratat & Oumtanee, 2009).
The participants stressed the importance of learning how to talk to other members of the
health care team, and how to speak up for their patients. For example, Participant 6 stated, “My
preceptor was there the whole time supporting me and the manager came out later and told me I
did I good job.” This is supported by the literature, which stresses the importance of positive
role modeling and socialization in assisting new graduates’ nurse development and how they
interact within the organization (Baldwin, Birks, & Budden, 2014; Dinmohammadi et al., 2014;
Lai & Lim, 2012; Price, 2009). The participants’ comments support the literature, in that
preceptors, managers, and peers need to be aware that new graduate nurses need extra assistance
in developing socialization and communication skills.
Reality Shock and Burnout
These topics, as discussed in the literature review in chapter two, were not specifically
discussed among the participants. Several possible hypotheses for these omissions will be
discussed in this section. Kramer, Maguire, and Brewer (2011) collected data from 468 new
graduates at three intervals during the first year of practice. Those researchers were specifically
looking at the impact healthy work environments play in reducing reality shock. The researchers
concluded that a healthy work environment had a positive effect on new graduates. The new
graduate nurses who were interviewed for the present study made numerous comments about the
positive work environment they were in, “everyone has been very supportive,” “I feel I can go to
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my manager with anything,” “the nurses on the unit were very welcoming,” and “ it helped I had
clinical on the unit I was hired to.”
Importantly, all ten participants had worked less than one year at the time of this study,
and follow-up at 12, 18, and 24-months might yield interesting results vis-à-vis reality shock. It
is also possible that since Salem Health is the main hospital in the area where nursing students
perform their clinical rotations, participants might have had a more realistic idea of what was
expected when they started working at this hospital as compared to other studies’ participants.
As mentioned in the literature review, the research pertaining to burnout among new
graduate nurses is still fairly new. The published literature suggests that it can take up to three
years for new graduates to experience burnout (Rudman & Gustavsson, 2012). Positive and
supportive leadership can promote the retention of new graduates and reduce their feelings of
emotional exhaustion (Laschinger, Borgogni, Consiglio, & Read, 2015; Laschinger & Fida,
2014; Laschinger, Wong, & Grau, 2013). As stated above, each of the ten participants for this
study had worked for less than one year at the time of interviews. The researcher suggests a
more longitudinal study by revisiting these same participants at 18, 24, and 36-months to
determine whether they are exhibiting any symptoms indicative of burnout. The researcher
hypothesizes, based on the preponderance of positive comments from the participants pertaining
to the leadership they have encountered so far, that if the new graduates did experience burnout
within the next two to three years, then the cause would be from other issues.
Discussion
The interviews and the subsequent data gathered unveiled the new graduate nurse needs
the support of a preceptor during their transition to clinical practice. The findings relating to the
essence of the lived experiences of these ten participants are shared with detailed narratives to
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support findings and confirm authenticity. The data analysis revealed five main themes that
conveyed the essence of the lived experience of the participants. The five themes were:
communication and trust, manager support, developing technical skills, confidence
improvement, and role model and socialization. However, while this study aligns with current
research in citing the need that exists in the profession, it goes further in presenting a detailed
report of the lived experiences of new graduate registered nurses in their professional
journey.
The opinions expressed by these participants support Casey et al.’s (2004) assumption
that continued education is essential for new graduate nurses’ professional growth. If new
graduate nurses are leaving the hospital setting because they feel inadequately prepared, then it is
problematic for all stakeholders. High turnover can be costly for employing organizations,
harmful to careers, and most importantly, patient safety (IOM, 2010). Kovner, Brewer, Fatchi,
and Jun (2014), as well as Anderson et al. (2012), discussed the high cost employing
organizations incur as a result of high turnover among new graduate nurses. The findings in this
study support the findings of Casey et al. (2004) regarding the difficulties new graduate nurses
face in the clinical learning environment upon leaving nursing school and upon entry into clinical
practice. These difficulties include, but are not limited to, developing communication skills and
trust among coworkers (theme one); the continuing development of technical skills (theme
three); improving self-confidence levels (theme four); and socialization within a new
environment (theme five).
It is imperative new graduates seek learning experiences in order to develop the necessary
skills to function in the fast-paced health care setting. This is not limited to technical skills, but is
inclusive of other skills as well, such as critical thinking and communication. It is also important
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to note that managers and nurse educators have the responsibility to make sure these learning
opportunities are available for the new graduate. The implication is that new graduate nurses
must learn to develop skills, both technical and non-technical, in order to provide safe patient
care as well as to continue within the profession itself. Benner’s (1984) model of novice to
expert articulates the skill acquisition process for graduate nurses well.
Benner’s From Novice to Expert Theory (1984) was used as the theoretical framework
for this research study. The transition from novice nurse to advanced beginner to competent
nurse is the goal of many new graduate nurse residency programs. New graduate nurses today
enter practice at the novice level. According to Benner’s (1984) research, new graduate nurses
need support, be it a preceptor, nurse educator, or nurse manager, to transition from nursing
student to professional nurse. Benner’s theory also describes the way new graduate nurses
acquire and develop skills needed in their new environment.
Benner (1982) used a phenomenological design to examine how nurses gained
information to acquire new skills, by listening to the nurses’ stories and determined that nurses in
the novice and advanced beginner stages need support through orientation programs to gain
skills and competence. Benner identified implications for teaching and learning at each
developmental stage (Benner, 1984). At the novice level, nurses have little to no understanding
of how to apply what they learned from textbooks to real patients in the hospital. The novice
nurse relies on rules without the benefit of experience to bring context to the application of the
rules. Benner noted that skill or talent does not define the novice stage; on the contrary, it is
situational.
The participants in this study were novice nurses. As stated in their own words during
the interviews, they had little to no understanding of how to apply what they learned in nursing
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school to real life clinical situations. Like the novice nurse described by Benner (1984), the
participants lacked experience to bring context to the application of what they learned in school.
As the participants described, the book knowledge from school amounted to random information
that had little meaning until they had the opportunity to work with the knowledge in the clinical
setting with a preceptor. Participating in a new provided the experiential learning necessary for
the advancement to the next stages of professional development.
This study supports Benner’s (1984) theory as she defines the novice nurse, one having
little or no experience. The participants, like novice nurses, relied on preceptors, concrete rules,
and manager support to guide them in their professional development. Novice nurses need
affirmation of a job well done, understanding from other health care workers, and most
importantly of all, positive reinforcement from preceptors and nurse managers. New graduate
nurses require the experiences, which over time, will assist them in developing and expanding
their body of knowledge and making a positive contribution to the nursing profession.
Today, health care organizations are increasingly reliant on graduate nurses to fill existing
nursing vacancies as the nursing shortage continues to worsen (AACN, 2015b; Littlejohn,
Campbell, Collins-McNeil, & Khaylie, 2012). Therefore, it is imperative that health care
organizations provide continuing education for new graduate nurses in order to make sure they
have a basic level of clinical and non-clinical competency, and based on the findings in this
study, to assure they transition in an effective and appropriate manner. This is vital if the new
graduate is to function effectively and continue to progress in their professional practice setting.
The idea of continuing education to support and enhance graduate nurses’ professional
growth within the health care learning environment is strongly supported by the literature and
this study (Casey et al., 2004; Chandler, 2012; Cylke, 2012; Goode et al., 2009; Hoffart,
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Waddell, & Young, 2011; Lee, Tzeng, Lin, & Yeh, 2009; Scott, Engelke, & Swanson, 2008;
Trepanier et al., 2012). Results from multiple studies have recommended developing a
structured residency program with a preceptor component as an effective tool for transitioning
new graduate nurses from the educational to practice setting (Al-Dossary, Kitsantas, & Maddox,
2014; Anderson et al., 2012; Barnett, Minnick, & Norman, 2014; Callaghan et al., 2009;
Cockerham, Figueroa-Altman, Ross, & Salamy, 2011; Croxon & Maginnis, 2009; Elmers, 2010;
Gross Forneris & Peden-McAlpine, 2009; Hoffart, Waddell, & Young, 2011; Marks-Maran et
al., 2013; McCarthy & Murphy, 2008; Murphy-Rozanski, 2008; Robitaillee, 2013; Rush et al.,
2011; Shinners, Mallory, & Franqueiro, 2013).
Recommendations
This study explored new graduate nurses’ interactions with preceptors during the course
of a residency program. A review of the literature revealed several qualitative studies
highlighting the stressful nature of this fast-paced working environment and the potential impact
on recent graduates (Anderson et al., 2012; Yeh & Yu, 2011). Prior research indicated that
newly employed graduate nurses tend to leave their place of hire within the first two years of
employment (Anderson et al., 2012; Arnold, 2012; Bratt, 2009; Kovner et al., 2014). Therefore,
it is crucial that health care organizations are aware of the issues new graduate nurses face as
they enter in the clinical environment and help to mitigate them.
It is recommended health care organizations should continue to provide a supportive
learning environment for the new graduate to acquire necessary skills, both technical and non-
technical, in order to become a competent and safe practitioner. A supportive learning
environment includes having a competent preceptor during orientation, as well as support from
nurse educators, managers, and other members of the health care team. Health care leadership
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needs to take the appropriate steps to ensure new graduates’ initial clinical experiences are
structured, providing a new graduate residency program with a preceptor component to put them
on the path to competency, commitment, and retention. The experiences of these ten new
graduate nurses may inform what nurse preceptors, nurse educators, and schools of nursing need
to know to improve the competency and retention of new graduate nurses.
It is recommended based on theme one, communication and trust, managers and nurse
educators look at the teaching style of the preceptor and to match them with the learning style of
the individual new graduate. Or, at the least, the preceptors must recognize different learning
styles and be aware of their own teaching style. Participants that had a more negative experience
commented on the lack of being matched with a “like-minded” preceptor. They stated there was
“tension” and they “struggled” at times due to mismatched learning and teaching styles along
with differences in personality, which was “disastrous” and had a “negative impact” on the
orientation process.
Based on theme two, manager support, it is recommended that managers and preceptors
look at the new graduates’ schedule in order for the new graduate to get the most out of their
preceptor experience. Having the new graduate and preceptor work eight-hour shifts instead of
twelve-hours would allow the new graduate more time on the unit, being exposed to different
situations, and have time to review at the end of the day. For example, as Participant 6 felt, his
preceptor “was too tired at the end of the day (12-hour shift),” while Participant 7 shared, her
preceptor “didn’t have time to review the day… was tired and just wanted to leave,” and
Participant 10 commented, “I was too exhausted on day three (12-hour shifts) to really get much
out of the experience.” Other recommendations from the participants include, from Participant
3, “I would have preferred two days in a row, a day off, then one day on,” Participant 4 “Having
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time with my preceptor away from the floor would be great,” and Participant 5 “Maybe meeting
for two hours on a day off to review where I was and to talk about the week.”
The majority of the participants reflected upon their time with their preceptor in a
positive way, but commented they wish it could have been extended. The scheduled time
allotment for preceptorship clinical experiences ranged between 5–15 weeks or more; depending
upon the unit they were working in and their needs. Participants felt they were “rushed to
complete their orientation period,” and “that six weeks is a little bit short.” The difference in
orientation time between new graduates who had done their clinical (nursing school) at the
hospital and those who did not was also discussed.
Based on theme three, developing technical skills, it is recommended new graduates are
given more time to develop their technical skills. Be this in a simulation lab or on the working
unit. Participants commented they learned some skills in school, but had either not practiced
them for “some time,” or had “not really felt comfortable doing them.” Additional comments
included, from Participant 2, “I only did it (a skill) in the lab in school on a mannequin …
needed more practice,” Participant 3, “Even during my clinical I didn’t have the chance (to
practice skills),” Participant 7, “The hospital uses different pumps then I was taught … needed
time to learn,” and Participant 9, “We only got a few hours during orientation to look at the
machines…would have liked more time.”
Finally, it is recommended based on theme five, role model and socialization, that nurse
managers and preceptors should look at the new graduate as an individual and not as a group
when it comes to orientation time. “They (those who had nursing school clinical on the unit) got
a shorter time and were working by themselves sooner. I’m glad I didn’t because they were
struggling after a bit,” Participant 7 reflected and Participant 8 commented, “I was just told one
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day that I was done and would be working the next week on my own. They (preceptor) said they
needed me to get on the schedule, so get ready.” Overall, participants reported mostly positive
experiences with their preceptors. A few closing comment form the participants include: “keep
the lines of communication open,” “be honest in what you’re saying,” “be professional and
friendly,” “don’t act like a know-it-all,” and “please be patient with me.”
Recommendations for General Practice
The evidence suggests that new graduate nurses employed in the health care setting will
potentially continue to leave unless measures are implemented to solve retention issues
(Anderson et al., 2012; Arnold, 2012; Bratt, 2009; Kovner et al, 2014; Yeh & Yu, 2011). Health
care organizations should consider establishing quality practice clinical learning environments,
which can be accomplished by developing collaborative interpersonal relationships and may
prove useful in reducing the stress on graduate nurses, thus encouraging them to remain in
practice.
It is important for nurse managers to understand and to be conscientious of the difficulties
new graduate nurses have in making the transition from student to professional. The importance
of a positive new graduate-preceptor relationship and teamwork is important in regards for
patient safety (The Joint Commission, 2008). Participants frequently described difficulty
communicating with physicians, peers, patients, and their families. Communication is a key
component in nursing, as it can have a direct impact on health care delivery and patient
outcomes. New graduates need all the encouragement they can get in order to develop self-
confidence. Nurse managers must take the opportunity to encourage graduate nurses and make
them feel a part of the team while bolstering self-confidence and self-esteem.
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As stated above, one of the major themes discussed by the participants was the need for
open communication and trust between themselves and their preceptor. This is crucial in
developing a positive relationship, which contributed to the success of the new graduates’
experiences and is also supported by the literature (Duteau, 2012; Yonge, Moore, & Spence
Cagle, 2012; Myrick & Ferguson, 2011). The majority of the preceptors were reported to have a
warm, inviting personality, which assisted in alleviating some of the new graduates’
apprehension. Matching teaching styles with learning styles has been widely discussed in the
literature as it relates to preceptor-preceptee (Anderson, 1998; Bott, Mohide, & Lawlor, 2011;
Carlson, Wann-Hansson, & Philhammer, 2009; Chase, 2001; Choi & Yang, 2012; Kelly, 2007;
Spurr, Bally, & Ferguson, 2010).
Being satisfied with one’s job, as well as the work environment, may lead to
organizational commitment and is essential in light of current nursing shortages. Research
shows that job satisfaction enhancement strategies are effective, not only in improving work
performance, but in reducing the turnover of nurses (Mohammad, Al-Zeaud, & Batayneh, 2011).
Along with communication, socialization is another important factor in new graduates’ success
in the workplace. Being able to work with other members of the health care team is essential for
successful patient outcomes.
Studies related to job satisfaction and retention among new graduate nurses has
established a pattern of decreased job satisfaction and increased potential to leave the profession
within the first two years of practice. Further study is needed to identify what factors contribute
to this dissatisfaction and the factors that contribute to the decision to stay or leave the hospital
setting. Statements form the participants in regards to the new graduate-preceptor relationship
and previous qualitative work would suggest that developing a positive trusting relationship
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might contribute to support and connectedness that ease this experience, but further study is
needed to determine how effective this may be. As the nursing shortage continues to impact
health care organizations across the nation, it is imperative that nurses be successfully
transitioned into their roles and that early attrition is minimalized.
Recommendations for Future Research
According to Benner (1984), the novice nurse needs time to develop skills and an
understanding of patient care. This can be achieved through a sound residency program as well
as a variety of experiences over the course of several years to become an advanced beginner
nurse. Further studies on residency programs should be evaluated for effectiveness to determine
whether such programs improve self-perceived levels of competence.
Additional research should also be done to determine whether the curriculum of a nurse
residency program is the contributing factor for increased self-perceived competency and
confidence levels as well as intent to stay or whether it is the emphasis on supporting the new
graduate at the bedside with a preceptor that has the greatest impact. Other studies assessing the
effectiveness of residency programs found that new graduate nurses had decreased satisfaction at
three and six months post hire and were most content in their job at one-year post-hire (Casey et
al., 2004; Fink et al., 2008; Kowalski & Cross, 2010; Olson-Sitki, Wendler, & Forbes, 2012).
Future studies should look to employ either quantitative, mixed-method, or longitudinal
study designs to investigate this phenomenon further. Having a discussion group with the new
graduates after the initial interviews might have provided richer data with which to describe their
experiences, as the participants would get the opportunity to share with their peers. This might
trigger some lively discussion and bring up aspects of their shared experiences not thought of
individually. An experimental study is another approach to investigate comprehensive versus
115
non-comprehensive preceptor programs. The control group would consist of new graduates who
participate in a non-comprehensive program, while the experimental group participates in a
comprehensive preceptor program. A quantitative way to measure progress would then be
devised to compare results.
A statistical analysis regarding outcome such as new graduate nurse retention, hospital
return on investments, or turnover intention of new graduate nurses could be explored. The lived
experience of participating in a structured preceptor program and the lived experience of the
preceptorship from the preceptor’s perspective could also be investigated. Lastly, a longitudinal
study is recommended to investigate the length of a nurse residency program and its effects on
new graduate nurse transition unto practice, as the participants in this study completed the
preceptorship portion of the residency program at various lengths. As the participants discussed,
they wish they had more time with their preceptor to develop both technical and non-technical
skills, build self-confidence, and to expand on their critical thinking development.
Another recommendation for future study is to explore the effectiveness of nursing
educators in preparing new graduate nurses to enter the clinical arena. Many of the participants
indicated they did not feel well prepared to practice at the initial start of their experience, yet did
feel more confident by the end of their experience. Educators, both clinical and academic, may
want to look into this matter to determine why this is the case. A comparative study could also
be done across nursing programs in conjunction with health care settings to examine the
educational preparation for practice.
A final recommendation for future study would be to evaluate the effectiveness of
preceptor teaching styles and their effects on new graduate nurses’ learning using a non-
experimental correlation design. The role of the preceptor is vital in assisting the new graduate
116
to bridge the theory–practice gap, build confidence, promote job satisfaction, and support the
new graduates’ overall journey. As noted earlier, several of the participants commented on the
teaching styles of preceptors and their own learning styles, whether matching or not.
The findings of this study add to and support the body of current nursing knowledge.
Implementing these recommendations may improve job satisfaction, which may in turn lead to
higher retention rates, and most importantly, positive patient outcomes. By not implementing the
proposed recommendations, the rate of turnover for new graduates may remain high, costing
health care organizations tens of thousands of dollars a year, and play a major contributing factor
to poor patient outcomes.
Conclusions
The first three chapters of this thesis formed the foundation of this study. Chapter one
outlined the significance of the research problem, and detailed the research question, the
researcher’s position statement, and the theoretical framework used to guide this research. It is
essential that all stakeholders understand the reasons why so many new graduate nurses leave
their jobs within the first two years of employment, thus allowing appropriate actions to be taken
to ensure job longevity. The shortage of graduate nurses as a result of high turnover rate may
have adverse effects on the quality of care provided to patients. One way to assist the new
graduate in their transition from nursing school to employment is through a new graduate nurse
residency program, with a preceptor component. This study used random sampling to select ten
new graduate nurses who met the inclusion criteria for the study.
Chapter two outlined the current state of the literature in regard to issues faced by new
graduate nurses as they enter the workforce. These issues include problems related to a lack of
critical thinking skills, technical competencies, self-confidence, socialization/communication,
117
reality shock, and burnout. The literature presented in this chapter also described the core
components of a new graduate nurse residency program.
Chapter three provided a discussion of the research design used in this study. This
chapter also outlined participant recruitment, data collection and storage, as well as the methods
of data analysis. At the time of this study, all participants were employed in the hospital setting
at Salem Health in Salem, Oregon.
Chapter four presented the results and the five themes that were developed from the
interviews. These themes include: (1) the new graduate nurses’ need for open communication
and trust between themselves and their preceptor; (2) a need for managerial support; (3) the
developing of technical skills; (4) confidence improvement; and (5) role modeling and
socialization.
In Chapter five the researcher reviewed and discussed the interpretation of the primary
findings in relation to themes discovered in Chapter four. These themes included:
communication and trust; manager support; developing technical skills; confidence
improvement; and role model and socialization. These themes were addressed in detail and an
overall discussion followed with supportive literature. A discussion of these themes and how
they relate to the themes critical thinking, technical competency, confidence improvement,
socialization and communication, reality shock, and burnout, discussed in the literature review of
Chapter two followed. Finally, the theoretical framework, Benner’s (1984) Novice to Expert
used in this study was discussed.
While the literature suggests that reality shock and burnout are key issues faced by new
graduate nurses, the participants in this study did not allude to either of these issues.
Consequently, the author hypothesized various reasons for the absence of these issues from the
118
participants’ experiences. The results provided insight to the central research question and
provided further understanding of new graduate nurses’ perspectives of their preceptorship
clinical experiences. Findings were supported by sound examples from the data generated by the
sample. The researcher offered recommendations based on the themes presented by the
participants as well as recommendations for practice and future research.
The aim of this study was to explore the lived experience of new graduate nurses during
their interactions with their preceptors. This study uncovered various issues related to the
transition from nursing school to employment as described by new graduate nurses. By giving
voice to their experiences this study presented a distinctive and inclusive approach to
understanding the difficulties new graduate nurses face during the transition. Detailed
descriptions were collected through a semi-structured interview that provided a broad perspective
of the participants’ experiences. During the analysis of the data, several themes emerged which
were later discussed in relation to the lived experience of the new graduate nurses.
The findings of this study validate the need for preceptorships in order to enhance the
critical thinking, confidence, and support of new graduate nurses. The themes that emerged
within this study provide a thorough view of the experiences as described by those undergoing
the phenomenon: the interactions of the new graduate nurses with their preceptors. The high rate
of turnover among new graduate nurses supports the need for programs to facilitate the transition
of new nurses into clinical practice. The new graduate nurse needs support as they make their
transition into the workforce, be it the development of technical skills, critical thinking,
establishing relationships, navigating the organization, or developing self-confidence. The
findings and conclusions of this study have practical implications for efforts to address the
transitional experience of new graduate nurses.
119
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Appendix A: Northeastern University’s IRB Approval
163
Appendix B: Salem Health’s IRB Approval
164
Appendix C: Interview Guide: Face-to-Face Interview, Audio Tape Recorded
1. How would you describe the relationship you had with your preceptor during your
orientation process? Can you tell me how you perceived support you received from the
preceptor and how important that was?
2. How would you describe the opportunities you experienced to develop or improve
skills (clinical/non-clinical) during the preceptorship experience?
3. Based from your experiences with you preceptor, are there any challenges that may
have enhanced or hindered the success of you preceptorship? Why or why not do you
think these were challenges?
4. What occurred during the orientation process with your preceptor that made you feel
secure in your nursing practice knowledge? Was there a specific event or moment?
5. How do you feel this experience has prepared you to enter the workforce safely as
professional nurses? How did you know you were ready for independent practice?
6. Do you have any other comments to share?
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Appendix D: Participant Demographics
What type of degree did you obtain from your nursing school?
Associated Degree Nursing: 2
Bachelor of Science Nursing: 8
What is your gender?
Female: 9
Male: 1
What is your age?
18–24: 2
25–34: 7
35–44: 1
While you were in nursing school, did you participate in a clinical rotation at Salem Health?
Yes: 5
No: 5
What unit at Salem Health were you hired to work?
Medical/Surgical: 6
Critical Care: 2
Mother/Baby: 1
Emergency Room: 1
How long was your orientation with your preceptor?
1–4 Weeks: 0
5–9 Weeks: 5
10–14 Weeks: 4
15 or more weeks: 1
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Appendix E: Excerpts of Field Notes from Participant Interviews
Thoughts Prior to
Interviews
Observation During
Interviews
Reflections After
Interviews
�Very nervous, what if no one shows up? �What happens if I don’t get enough data? �What if they don’t answer the questions or don’t understand the questions? �Do I have enough questions to gather enough data? �Glad I practiced asking questions �Stay on topic �Let them talk freely, may gain additional data �Make sure I stay on topic �Don’t start adding your own thoughts, let them talk. �What if the recording fails? �How fast can I write? �Remember to be nonjudgmental �Remember open-ended questions �I am the researcher, not their best friend, be professional �Hey, I am getting the hang of this �Need to keep the questions the same, cannot make major changes or add – this would distort the data �Take your time, do not rush through � This is a lot of data, hope I can code this correctly �Last one! So far no one has backed out
�Maybe they are more nervous than I am; need to make them feel at ease. �Smiling, sitting back, relaxed. �Remember to let them talk. �Prompt for more information if needed. �Some of them are very passionate about their experiences �Off subject, need to redirect them �Needing to take a break �Getting a bit off topic, need to redirect back �Angry at first about experience, very animated, calmed down as we moved on �Very serious �Wondering if they thought the interview was not an option �Remember not to comment, as I know the person they are talking about �Kept looking at the clock �Seemed a bit nervous at the start �Very calm and relaxed �Interesting to note the differences in body language
�That went a lot easier than I thought. �They had a lot of great information. �It was difficult not to interject my own opinion or offer suggestions �I felt they really wanted to help �Interested in the research �Care about their coworkers �Excellent descriptive information �I feel I remained un-biased, so they could talk freely �Wanted to ‘gossip’ afterwards about the clinical site �Excellent talker, very articulate �Didn’t have to repeat or rephrase as often as I thought I would have to �I felt bad about the participants experience, glad it worked out in the end �Seemed cautious, not very forthwith. Answered all the questions �Once they got going, they had a lot to share �Was expecting some sort of feedback at the end �Few minutes late, came with child �I have a hard time just being the observer, want to interject and participate, share my experiences
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