Wolters Kluwer Health, Inc.

Graduate Nurse Transition Program

Author(s): Dianne L. Borovies and Nancy A. Newman
Source: The American Journal of Nursing, Vol. 81, No. 10 (Oct., 1981), pp. 1832-1835
Published by: Lippincott Williams & Wilkins
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Graduate Nurse
Transition
Program
Coauthor
Nancy
Newman
(1)
and new
graduate
Pat
Campbell
discuss rotation with RN
Colleagues
inGNTP.
By:
Dianne L. Borovies
Nancy
A. Newman
A number of
programs
have been
devised to
help
the new
graduate
adapt
tothe
shock-producing
situa-
tionshe encounters whenshe leaves
school and
begins
work ina
hospital.
Not
only
does the new
graduate
face a conflict betweenvalues and
behaviors she knew as a
nursing
stu-
dent inaneducational
setting
and
those of a new
graduate
inher first
work
situation,
but she alsofinds
that her theoretical
knowledge
is of
little use toher until she no
longer
is
anxious about her clinical skills.
The Graduate Nurse Transition
Program(GNTP)
was
designed
to
assist such nurses tobecome com-
fortable as members of the health
care teaminthe realistic work set-
ting
of a small to moderate-sized
acute care
hospital
inNorthernVir-
ginia.
It is a
practical guided experi-
ence for
beginning
level staff
nurses, structured toenable
them,
at
its
end,
to functionas
beginning
staff inthe critical care area.
The
nursing
administrators'
concerns that new
graduates
come
tothe
hospital setting
with limited
clinical skills were corroborated
by
a 1978
"Nursing Survey Question-
naire" of the
Virginia Hospital
Asso-
ciationCommittee on
Nursing,
in
which a
majority
of the
respondents
indicated that associate
degree
and
baccalaureate nurses lack
adequate
entry-level
clinical
skills(l).
Carozza
cites a ColoradoNurses Association
statement
pointing
out serious inad-
equacies
inthe clinical
performance
skills of new
graduate nurses(2).
Inour interviews with several
nursing
administrators the
point
was
made that
generalized
orientation
programs usually
are not
long
enough
or intensive
enough
tode-
velop adequately
the new
grad-
uate's
proficiency
inclinical skills
and
independent functioning.
Arm-
DIANNE L BOROVIES, RN, MSN, is associate direc-
tor of
nursing,
Children's
Hospital
National
Medical Center, Washington,
D.C.
NANCY A. NEWMAN. RN, MSN. (XRN, is the nurs-
ing
educationcoordinator, acute care, Lou-
dounMemorial
Hospital, Leesburg,
Va.
This article is based onthe
unpublished
manuscript,
"A New Graduate Nurse Transi-
tion
Program-An Application
of the Princi-
ples
of Facts and
Planning
for
Introducing
New Graduates intothe
Hospital Organiza-
tion," by
Ms. Borovies, Ms.
Newman, and
DawnB.
Rigney, RN, MSN.
1832 American Journal of
Nursing/October 1981
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All use subject to JSTOR Terms and Conditions
strong
documents criticisms of such
programs
as too brief and too
geared
toa
specific
institution's
pol-
icies and
procedures(3).
Inour area
of Northern
Virginia,
vacancies
were
high
incritical care staff
posi-
tions,
and while new
graduates
of-
ten
expressed
a desire towork in
critical care
areas,
most institutions
required
at least one
year
of
gener-
alized
medical-surgical experience
before such an
assignment.
Admin-
istrators
complained
that new
grad-
uates oftencame totheir small insti-
tutions for aninitial
medical-surgi-
cal
experience
and thenleft as soon
as
they qualified
for critical care
positions
in
larger
medical centers.
Whenwe
planned
the
GNTP,
no
transition, internship,
or
precep-
tor
programs
were
being
offered in
the Northern
Virginia
area for new
graduate
nurses. While administra-
tors were aware that such
programs
were
costly, they agreed
that the
long-range
benefits of
potential
con-
tinuing employment might
offset
the short-termcosts.
We also talked with recent
graduates
from
associate,
baccalau-
reate,
and
diploma programs
who
willingly
shared with us memories
of their first few months as staff
nurses at area
hospitals. They
de-
scribed their acclimationas a "sink
or swim"
experience. They
said
they
oftenfelt
caught
ina dichoto-
mous
situation; they
were
eager
to
assume
professional
roles as
patient
advocates, change agents,
and care
givers
but felt stifled
by hang-ups
over their lack of
experience
inclin-
ical skills and
organizational
abili-
ties.
They
did not feel
competent
in
performing
a
majority
of clinical
skills and had
difficulty integrating
theory
to
practical experience.
They
felt unable to
organize
and
delegate effectively
and effi-
ciently
and were uncertainabout
the
roles, authority,
and
responsibil-
ities of the various members of the
health care team.
The
program
we devised had
its
pilot
trial at LoudounMemorial
Hospital, Leesburg, Va.,
a 107-bed
rural
community hospital.
The terminal
objective
of the
six-month
program
was stated as
follows:
Having completed
the six-
month
GNTP,
the nurse will be
able to meet the criteria
for
a
beginning
level intensive care unit
(ICU) staff
nurse as outlined inthe
organization's staff
nurse
job
de-
scription.
We
designed
the
program
to
include two modules. Module A
would runfor 12 weeks and
empha-
size
generalized medical-surgical
nursing. Upon
successful
comple-
tion of Module A, a
participant
could
begin
Module
B,
which cov-
ered 12 weeks of
introductory
criti-
cal care
nursing.
We created anassessment tool
that would determine the skills the
participant possessed upon entry
intothe
program
as well as indicate
the
appropriate experiences
re-
quired
to meet the
participant's
needs
throughout
the
program. By
developing
our GNTP clinical skills
assessment in two
components-a
checklist to
correspond
with each
module with columns for sevendif-
ferent assessments-we were able to
build an
ongoing
evaluationand
feedback
system
intothe
program.
In
addition,
the Nurse Profile
Assessment was
developed
sothat
participants
could formulate their
own
objectives
for each of the two
modules.
Leypoldt
stresses the value
of learners'
setting
their own
goals
as well as the need for instructors
and learners to evaluate
progress
periodically
toward attainment of
these
goals(4).
A review of
internship
and
pre-
ceptorship programs reported
inthe
nursing
literature showed a
variety
of ratios of didactic to
experimental
hours. Inthe
GNTP,
each module
includes clinical
experience
onall
three shifts with a 1:2 ratioof class-
roomtoclinical
practice.
Clinical
experience begins
briefly during
the
hospital's gener-
alized orientation
program,
which is
part
of Module A.
Participants'
eight-hour-day experience
with
pa-
tients
begins
the third week and
continues
throughout
the GNTP
with the
exception
of time
spent
in
classroom, group,
or
counseling
ses-
sions. The number of
patients
as-
signed gradually increases,
and the
amount of unit
responsibility
dele-
gated
tothe new
graduate
advances
as the individual
progresses through
the
program. Experience
includes
weekends and rotationtoall three
shifts.
Participants
are not counted
inunit
staffing patterns but, rather,
as additional nurses
assigned
tounits
to
acquire
needed skills and
experi-
ence.
The clinical
experience pro-
vided inboth modules is
augmented
by continuing
clinical
supervision
and
support
fromanRN
Colleague.
Inthe
medical-surgical module,
the
colleagues
remainontheir
respec-
tive shifts while the
participants
ro-
tate. Inthe intensive care
module,
however,
the
colleagues
and
partici-
pants
rotate
together.
The
colleague
functions as the new
graduate's
mentor while inthe clinical area. It
is the new
graduate's responsibility
toseek out assistance whenever she
feels the need for it. Such
guidance
and
support strengthens
self-confi-
dence and
feelings
of
responsibility
and
encourages
initiative inthe use
of
support resources(5).
The RN
Colleagues
receive an
orientationtothe GNTP and tothe
philosophy
of the
colleague concept.
While no
monetary
incentive is of-
fered tothe RN
Colleagues,
nurses
functioning
inthis role
experience
enhanced self-worth and a
feeling
of
contributing
to the
profession.
Colleagues
have the
option
of
keep-
ing
a
log
of
prn
entries of concerns
and
positive
or
negative
comments
or both
regarding
the
GNTP; this
serves as a communicationtool be-
tweenthe
colleagues
and the staff
development
instructor
responsible
for
coordinating
the
program.
Addi-
tional classroomand clinical content
suggested by
the RN
Colleagues
may
be
incorporated.
We have found recent
grad-
uates
extremely receptive
to the
idea of a
daily diary
as a
way
to
keep
a
running
anecdotal account of
events and activities. As
part
of this
program,
the
diary
serves as a basis
for discussionat
diary-sharing
ses-
sions or inone-to-one conferences
betweeneach
participant
and the
staff
development
instructor. Green
and Stone
point
out that oftendia-
ries can
provide
clues to
unthought-
of issues or
problems
for formal fol-
low-up
at
subsequent times(6).
Six 90-minute
reality
shock
rap
sessions are held weeks 13
through
18 to
discuss,
ina
supportive
envi-
ronment, topics
related todifficul-
ties encountered as new
graduates
adapt
tothe staff nurse role. Each
participant
must attend a minimum
AmericanJournal of
Nursing/October
1981 1833
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All use subject to JSTOR Terms and Conditions
Module A
Objectives
Generalized
Medical-Surgical Nursing
First Twelve Weeks
Module A is
designed
to:
1. Facilitate the familiarizationof the new
graduate
with the
hospital
or-
ganization.
2. Increase the skills
proficiency
of the new
graduate
inthe medical-
surgical
staff nurse role.
3. Facilitate the attainment of the
participant's personally
defined
objec-
tives.
4. Foster the
positive psychosocial adaptation
of the new
graduate
to
the staff nurse role.
5. Provide
program
content tailored to
specific
needs of the
partici-
pant.
6.
Develop
the new
graduate's
clinical
proficiency
as staff nurse.
7.
Develop
the new
graduate's beginning leadership
role
ability.
Having completed
Module A, the
participant
will meet the
following
ob-
jectives:
1. Attend 100% of the
hospital's
two-week
(80-hour) generalized
orientation
program.
2.
Identify his/her limited skill areas and measure
his/her progress
inskill
development by completing
the GNTP Clinical Skills Assess-
ment
every
three weeks and
by adequately performing
a minimumof
75% of the skills listed onPart I, General
Experiences.
3.
Complete
the Nurse Profile Assessment and list three
personal
objec-
tives for Module A and assess
progress
in
meeting
these
objectives.
4. Maintainan
up-to-date
account of
experiences
ina
daily diary
and
be introduced tothe
concept
of
reality
shock.
5.
Participate
innoless than90% of all offered classroomand clinical
experience
as well as
present
twohours of
individually
selected
nursing-related
material.
6. Functionas staff nurse onall three shifts and attain100% of items 1,
2, 4, 6, 8, 9, 12, and 14-17 of Level 1 Professional Performance
Ap-
praisal
standards.
7. Functionas staff nurse onall three shifts and attain100% of items 3-
8, 10, 11, 13, and 17 of Level 1 Professional Performance
Appraisal
standards.
Module B
Objectives
Introductory Medical-Surgical
Intensive Care
Nursing
Second Twelve Weeks
Module B is
designed
to:
1. Orient the new
graduate
tothe intensive care unit
(ICU).
2. Introduce the skills basic tothe ICU tothe new
graduate.
3. Facilitate the attainment of the
participant's personally
defined
objec-
tives.
4. Foster the
positive psychosocial adaptation
of the new
graduate
to
the staff nurse role.
5.
Develop
the new
graduate's beginning
ICU clinical skills and lead-
ership
abilities.
Having completed
Module B, the
participant
will meet the
following
ob-
jectives:
1. Attend 100% of the ICU orientationsessions.
2.
Complete
the basic
coronary
care and the intensive care courses
and
perform
a minimumof 50% of the skills listed onPart II, ICU Ex-
periences,
of the GNTP Clinical Skills Assessment.
3.
Complete
the Nurse Profile Assessment and list three
personal objec-
tives for Module B and assess
progress
in
meeting
these
objectives.
4.
Participate
infive of six 90-minute
reality
shock
Rap
Sessions and
maintainan
up-to-date daily diary
of
experiences.
5. Functionas staff nurse onall three shifts inICU and attain100% of
the items of Level 2 Professional Performance
Appraisal
Standards.
of five of the six sessions toremain
inthe
group.
The
group
consists of
the GNTP
participants
and us.
Whenthe
program
was insti-
tuted at LoudounMemorial
Hospi-
tal, specific
items fromthe
hospital's
professional performance appraisal
were
incorporated
into the be-
havioral
objectives
for both modules
of the
program.
These resulted in
clearly
stated
performance
criteria.
It was decided that the
nursing
department
could accommodate a
minimumof four and a maximum
of six new
graduates
in the
pro-
gram.
A brief
description
of the
pro-
gram
was sent toschools of
nursing,
and interested senior students and
new
graduates
were interviewed
and selected
by
the assistant direc-
tor of
nursing.
Head nurses selected
the RN
Colleagues
who then at-
tended a GNTP orientationsession.
A critical care nurse clinicianem-
ployed
at Loudoun
developed
the
coronary
care and the intensive care
courses for Module B.
A modificationof the
program,
which
nursing
administration
thought necessary
to
help
offset im-
plementationcosts,
was the
require-
ment that GNTP
participants sign
a
statement of intent
(recognized
as
not
legally binding)
toremainwith
the institutionfor six months
upon
completion
of the
program.
Partici-
pants
would be
guaranteed employ-
ment with
preference
for ICU
posi-
tions as available.
The five GNTP
participants
se-
lected
joined
other new
hospital
em-
ployees
for the usual two-week
gen-
eral orientation.
Following
anas-
sessment of their
skills, the transi-
tion
program
was modified
slightly.
For
example, they
identified a need
for minimal review ontractionand
cast care and asked for additional
content onassertiveness and mecha-
nisms for
coping
with
stress,
as well
as a detailed
coverage
of such
topics
as "Care of the Patient with COPD"
and "Care of the Post
Myocardial
Patient."
Inthe
early
weeks of clinical
experience,
the transitionnurses
thought
their increase in
patient
as-
signments
should be
gradual.
But
by
the end of the fifth week of the
pro-
gram,
the head nurses found that
the new
graduates
could assume
maximum
patient assignments
and
attributed this tothe
support
from
1834 AmericanJournal of
Nursing/October
1981
I
0
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All use subject to JSTOR Terms and Conditions
the
program. By
the end of Module
A,
the nurses
appeared
confident
and comfortable with their
assign-
ments.
The fear and
anxiety
of the
transitionnurses was
apparent
with-
in the first two weeks of clinical
assignments.
Because of their anxi-
ety, diary-sharing
sessions were held
at the
beginning
of all class meet-
ings
before formal instructioncould
begin. They
felt overwhelmed
about
facing
crisis situations before
resolving
their ownfears and anxie-
ties about their
competency. They
found that
diary-sharing
sessions
helped allay
their anxieties
by pro-
viding opportunities
for
"just get-
ting
it out." Inour small
hospital
setting,
it was evident that
reality
shock arrived sooner thanantici-
pated.
We have continued tooffer
these
sharing
sessions
throughout
Module A onan
optional weekly
basis.
By
the time of the scheduled
reality
shock
rap
sessions inModule
B, participants
had resolved initial
anxieties and fears and were more
receptive
to
discussing
broader con-
cepts
of conflict resolutionand role
transformation. We believe that the
combinationof the
diary-sharing
sessions and the
reality
shock
rap
sessions contributed
greatly
tothe
positive psychosocial adaptation
of
the new
graduates.
Periodic evalua-
tions of
participants' progress
were
an
integral part
of the
program.
Evaluations included the
following:
*
Joint
review of the GNTP
Clinical Skills Assessment
by
the
participant,
the RN
Colleague,
and
the staff
development
instructor at
weeks
6, 9, 12, 18, 21,
and 24.
*
Joint review of the Nurse
Profile Assessment
by
the
partici-
pant,
the RN
Colleague,
and the
staff
development
instructor at
weeks
6, 9, 12, 18, 21,
and 24.
*
Joint
review of the
profes-
sional
performance appraisal by
the
participants,
the RN
colleague,
a
head
nurse,
and the staff
develop-
ment instructor at weeks 12 and
24.
*
Completion by
RN Col-
leagues
of a concise evaluationof
the GNTP and
participants
at weeks
6, 9, 12, 18, 21,
and 24.
*
Completion
of a
subjective
evaluationof Module A and of Mod-
ule B
by participants
at weeks 12
and 14
respectively.
*
Completion
of a
subjective
evaluationof the GNTP
by
the RN
colleagues
at the end of the
GNTP.
* An evaluation conference
with
nursing
administrative
person-
nel at the end of the GNTP todis-
cuss the
strengths,
weaknesses,
and
outcomes of the
program
and its
participants.
This
program
was not
designed
toresolve issues
involving
the rela-
tionship
betweeneducational
pro-
grams
and the skill levels of new
graduates
and the
expectations
of
employing agencies.
The GNTP
was
designed
to
provide
assistance
to
participants
inthe transitionfrom
student tostaff nurse. It alsowas
planned
as a
potential
recruitment
tool and aneffort that would de-
crease attritionrates of new
grad-
uates.
We believe that the GNTP aids
new
graduates
in
gaining
clinical
experience
and a realistic view of
hospital nursing by assisting
and
supporting
them
during
the critical
early
months of their careers.
References
1.
Virginia Hospital Association, Committee on
Nursing. Analysis of
1978
Nursing Survey
Questionnaire,
Part 1. Richmond, The Associa-
tion, Feb. 1979, p.
87.
2. Carozza, Virginia,
and others. An
experimental
educationally sponsored pilot internship pro-
gram. JNE 17:15, Nov. 1978.
3.
Armstrong,
M. L.
Bridging
the
gap
between
graduation
and
employment. J.Nurs.Adm.
4:42-43, Nov.-Dec. 1974.
4.
Leypoldt,
M. M. The
teaching learning process
with adults. Adult Lead. 16:213, Dec. 1967.
5. McGrath, B.J.,
and
Koewing, J.
R. A clinical
preceptorship
for new
graduate
nurses.
J.Nurs.Adm. 8:13, Mar. 1978.
6. Green, J. L., and Stone, J.
C. CurriculumEval-
uation:
Theory
and Practice. New York,
Springer Publishing Co., 1977, pp.
197-198.
AmericanJournal of Nursing/October
1981 1835
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All use subject to JSTOR Terms and Conditions