Article

Stresses and challenges for

new graduates in hospitals
Marilyn H. Oermann and Michael F. Garvin
As new graduates enter the workplace, they are faced with many stresses associated with
beginning practice. The nurse manager, preceptor, and nursing staff need to be aware of the
specific stresses and challenges experienced by new graduates during their orientation
period and need to plan interventions for coping with them. What stresses and challenges do
new graduates face in clinical practice? To answer this question, 46 new graduates completed
the Clinical Stress Questionnaire on which they rated their degree of stress and challenge in
clinical practice and the extent they experienced 20 different emotions while learning to care
for patients on the unit. They also described what was stressful and challenging for them.
This article presents the results of this survey and guidelines for mentoring new graduates
during the orientation period. & 2002 Published by Elsevier Science Ltd
Introduction
The knowledge and skills needed for entry
into nursing practice have expanded in recent
years. As graduates begin their orientation
programs, there is still much to be learned for
practice in most healthcare settings. New
graduates may lack an understanding of the
concepts and theories for care of patients in
the particular setting, they may have limited
technological skills, and their clinical
experiences as students may not have
adequately prepared them for beginning
practice.
For many new graduates, the orientation
period can be arduous. In addition to
acquiring competencies for patient care,
graduates also need to learn about the role
of the nurse and how to cope with other
demands, such as organizing care effectively,
completing assignments on time, and
working with unfamiliar staff. Much of the
learning that occurs during orientation is not
done in the classroom but takes place in
clinical practice as graduates learn how to
care for their patients and how to work
effectively in the agency.
Nurse managers, preceptors, and other
nursing staff have an important role in
identifying the clinical learning needs of
graduates, planning patient assignments to
meet those needs, and mentoring graduates so
they may cope more easily with the inherent
stresses and challenges of beginning practice.
Orientation programs are expensive for the
agency. To get the most out of the orientation
period, new graduates need a consistent
mentor, whether it be a manager, preceptor, or
colleague. Along with teaching new graduates
and serving as a role model, the mentor can
help them cope with other stresses they face in
beginning practice.
While some stress is motivating, too high a
level interferes with learning (Gaberson &
Oermann 1999). An understanding of these
stresses and the difficulties new graduates
have in their initial practice on the unit enables
the mentor to more carefully plan learning
experiences and provide the assistance needed
for graduates to adjust to the practice setting.
The mentor cannot effectively teach new
graduates and cannot adequately support them
without an understanding of the stresses,
Marilyn H.
Oermann PhD, RN,
FAAN, Professor,
College of Nursing,
Wayne State
University, Detroit,
Michigan,
Michael F. Garvin
MSN, RN,
Staff Nurse,
Department of
Veterans Affairs,
John D. Dingell
Medical Center,
Detroit, Michigan,
USA
(Requests for
offprints to:
MHO, 168 North
Cranbrook Cross,
Bloomfield Hills,
MI 48301-2508,
USA. Tel.: 1 248
594 6933;
Fax: 1 248594
6934;
E-mail: moermann@
msn.com)
Manuscript
accepted:
19 September 2001
& 2002 Published by Elsevier Science Ltd Nurse EducationToday (2002) 22, 225230 225
doi:10.1054/nedt.2001.0695, available online at http: // www.idealibrary.com on
1
challenges, and difficulties nurses experience
in beginning clinical practice.
Purpose
The purpose of the study was to describe the
stresses and challenges new graduates
experienced in their initial clinical practice in
hospitals. This survey of new graduates
extends earlier studies in which graduates
reported a moderate amount of stress in clinical
practice during the orientation period.
Literature review
Studies have shown that clinical practice
is stressful for new graduates and nursing
students. Oermann and Moffitt-Wolf (1997)
examined the stresses and challenges of new
graduate nurses during their orientation to the
clinical setting, and the relationship of these to
social support. Data were collected with the
Clinical Stress Questionnaire (CSQ) (Pagana
1989). New graduates reported a moderate
degree of stress in their orientation period
because of their lack of clinical experience
and organizational skills. There were no
significant relationships between social
support (having a preceptor and participating
in formal support groups) and degree of
stress. Although graduates who had
preceptors and support groups on the unit
did not have less stress, they reported that
their learning experiences with patients were
more satisfactory and stimulating. They also
developed more self-confidence than graduates
who did not perceive this support from their
preceptors or others on the unit.
In another study, Maben and Clark (1998)
interviewed 10 new graduates on their
transition from student to staff nurse.
Although these nurses consistently articulated
aspects of their role that they found enjoyable
and satisfying, all of them acknowledged
feelings of stress. This stress was related to
assuming increased responsibility, being tired,
informing patients and relatives of negative
findings, working with terminally ill and
dependent patients, discharging patients too
soon, and not having support from other
nurses.
Charnley (1999) conducted a similar study
using semi-structured interviews of 18 new
graduates. The interviews revealed that new
graduates had significant stress and anxiety
during the first 6 months in practice. The
nature of this stress appeared to relate to the
nurses' lack of confidence in their clinical
practice skills and to work-overload, leading
to graduates' perception of their inability to
deliver holistic care. The nurses also
experienced concern over the care delivered
by assistants, who often lacked knowledge
and ability to interpret findings, and stress
from feeling responsible for the care actually
provided by the assistants.
In a longitudinal study by Dearmun (1998),
10 pediatric nurses within 1 year of graduating
from nursing school in the UK were
interviewed four times. Stresses reported
related to caring for children and working
with their families, assuming new tasks and
responsibilities, and coping with work issues
such as poor staffing.
Nursing students have also described the
stressful nature of clinical practice. Using the
CSQ, Oermann and Standfest (1997)
examined the stresses and challenges of
nursing students (n 416) enrolled in
different clinical courses in 10 randomly
selected programs. There were significant
differences found across clinical courses.
Stress was highest for students enrolled in
pediatric courses and lowest for fundamentals
courses. Students also reported more stress
in clinical courses as they progressed
through the nursing program, with the final
semester before graduation being the most
stressful time for them (Oermann 1998).
Using interviews and observations of
students in the clinical setting, Wilson (1994)
found that students had six major goals to
meet in their clinical practice: to avoid
harming the patient, help patients, apply
theory to practice, develop clinical skills,
`look good' as a student, and `look good' as
a nurse. Students were anxious about making a
mistake that could harm the patient.
Other stresses, from the student's
perspective, are lacking knowledge and
skills for patient care, the changing nature of
patient conditions, uncertainty about clinical
decisions, and working with difficult patients.
Stresses and challenges for new graduates
226 Nurse EducationToday (2002) 22, 225230 & 2002 Published by Elsevier Science Ltd
Interacting with the teacher, nursing and
other hospital staff, patients, and family
members and being observed and evaluated
in the clinical setting also are stressful for
students (Gaberson & Oermann 1999,
Oermann & Lukomski 2001, Williams 1993,
Wilson 1994).
This research has emphasized the need for
support from the teacher and mentor to help
students and new graduates cope with the
stresses they experience in clinical practice.
Supportive relationships with the teacher
and mentor lead to development of
self-confidence and willingness to try new
approaches to care, knowing that an expert
is available to guide their decision-making.
By working closely with students and new
graduates in the practice setting and
accepting them as part of the team, the
teacher and mentor develop a climate that
supports learning and critical thinking (Myrick
& Yonge 2001). This climate, combined with
increasing responsibilities for patient care,
opportunity to practice skills, and consistent
feedback and clinical supervision, promote
learning in clinical practice (Lofmark &
Wikblad 2001).
Method
To examine the stresses and difficulties new
graduates faced in clinical practice, we
conducted a survey of 46 new graduates in
three hospitals in the Midwest region of the
USA. The nurses had been practicing as new
graduates for a mean of 2.74 months, and all
of them had completed the formal classroom
component of their orientation program. The
graduates were from associate (n 26) and
baccalaureate (n20) degree nursing
programs. They were working in medical/
surgical nursing (n 24, 52%), critical care
(n17, 37%), and other units in the hospital
(n5, 11%). Their mean age was 38.83 years
(SD9.03). The study was approved by the
Institutional Review Boards of the university
and participating hospitals.
Graduates completed the CSQ, which was
designed to assess the stresses, challenges
and emotions experienced by students in
clinical practice (Pagana 1989). On the CSQ
they rated, using a scale of 0 (none)
to 4 (a great deal), their degree of stress and
challenge in clinical practice and the extent
they experienced 20 different emotions while
learning to care for patients on the unit. They
also described in the open-ended questions
the types of experiences that were stressful
and challenging for them.
In the original evaluation of the CSQ by
Pagana (1989), factor analysis supported its
construct validity, and alpha coefficients were
between 0.84 and 0.85. Inter-rater reliability
for the open-ended questions was 0.89.
In the Oermann and Standfest (1997) study,
the alpha coefficient for the CSQ was 0.85.
A contact person was identified in the
staff development department at each
hospital, to assist in identifying current
graduate nurses at their facility. The new
graduates were asked in person to participate
in the study. An envelope containing
information about the study, the CSQ, and a
stamped envelope for return were distributed
to each potential participant. The nurses
mailed the completed instruments to the
investigators. No names or code numbers
were used.
Results
Stresses and challenges of beginning
clinical practice
New graduates found beginning clinical
practice on the unit moderately stressful;
the mean score was 2.30 (SD1.05), on a
scale of 0 (none) to 4 (a great deal). Even
though graduates found their clinical
experiences to be stressful, they were
challenged by them to an even greater
degree (Mean2.57, SD0.96). A one-way
ANOVA was used to determine if there were
differences in the amount of stress and
challenge based on the type of unit in which
graduates were currently working. There was
no greater stress or challenge if orienting to
critical care than to medical/surgical units.
There also were no differences based on the
type of nursing program graduates had
completed.
Through the open-ended questions, the
graduate nurses identified several stresses
they experienced during orientation to the
Stresses and challenges for new graduates
& 2002 Published by Elsevier Science Ltd Nurse EducationToday (2002) 22, 225230 227
unit. The stresses reported most frequently
were: (1) not feeling confident and competent,
(2) making mistakes because of increased
workload and responsibilities, and (3)
encountering new situations, surroundings,
and procedures. Other stresses are presented
in Table 1.
The greatest challenges faced by the new
graduates were applying the knowledge they
learned in school to their patients' care
and acquiring new skills. Other challenges
were assuming an increased patient
assignment and more responsibilities,
improving organizational ability and clinical
judgment, and caring for critically ill patients.
Using Pearson r, there were no significant
relationships between the degree of stress
and the graduate's age, months of experience
as a new graduate, years of past work
experience, and years of experience as a
nurse technician. There also were no
significant relationships between the degree
of challenge and any of these variables. There
appears to be a certain amount of stress and
challenge associated with beginning practice
regardless of the graduate's age and prior
clinical experiences.
Emotions experienced by
new graduates
New graduates rated the extent to which
they experienced 20 different emotions in
beginning clinical practice. Of the 11
emotions experienced most frequently, with
mean scores greater than 2, most were positive.
However, new graduates reported that they
were frequently anxious about caring for
patients and encountering new clinical
experiences (mean2.46), overwhelmed by
their assignments (mean2.32), and
apprehensive about caring for patients
(mean2.07) (Table 2). While most of the
graduates experienced positive emotions in
beginning practice, their anxiety in caring for
patients and with new clinical experiences
and being overwhelmed are important
findings of this study.
Implications for mentoring
new graduates
Nurse managers, preceptors, and other
co-workers can help support and nurture
the new graduate. If there is no formal
preceptor program, graduates should have
a mentor on the unit to make their patient
assignments, consider their individual
learning needs, and provide the instruction
they need to develop clinical competencies.
The mentor also serves as the expert with
whom the graduate can consult and ask
questions. The mentor should be aware of
typical stresses graduates face in beginning
practice new situations and procedures,
not feeling competent, difficulties in
managing increasing patient responsibilities
and workload, and concern about making
mistakes.
Table 1 Stresses reported by new graduates
(rank order by frequency)
Stresses
Not feeling confident and competent
Making mistakes because of increased workload and
responsibilities
Encountering new situations, surroundings,
and procedures
Inconsistent preceptors
Getting to know the staff
Encounters with unhappy nurses and other personnel
Short staffing
Staff nurses who were unwilling to help them
Table 2 Emotions experienced during clinical
practice
Emotion Mean SD
Stimulated 2.75 0.89
Hopeful 2.71 0.90
Excited 2.68 0.77
Happy 2.68 0.72
Eager 2.54 1.17
Anxious 2.46 1.04
Exhilarated 2.36 0.91
Overwhelmed 2.32 1.12
Pleased 2.25 0.84
Confident 2.11 0.88
Apprehensive 2.07 1.15
Worried 1.64 1.13
Intimidated 1.61 0.79
Relieved 1.57 0.69
Fearful 1.36 0.62
Disappointed 0.93 0.90
Disgusted 0.82 1.25
Sad 0.68 0.82
Angry 0.64 0.87
Guilty 0.54 0.88
Stresses and challenges for new graduates
228 Nurse EducationToday (2002) 22, 225230 & 2002 Published by Elsevier Science Ltd
Nurses working with new graduates,
need to be realistic about their expectations
of the graduates particularly as they relate to
clinical knowledge, critical thinking and
decision-making, and technical skills. All too
often experienced nurses set too high a
standard of care for new graduates. While
some graduates may meet these standards
and the expectations of the mentor, others
may need more time to develop their
knowledge and skills.
Teaching new graduates:
what is involved?
As a teacher, the mentor recognizes the
individual differences of each graduate and
wide range of competencies they bring to
their first nursing position. Rather than
viewing the new graduate as someone who
is not competent for practice on the unit,
instead the mentor plans patient assignments
and learning activities that enable the
graduate to develop the competencies that
are lacking.
Nurses enter practice with varying levels
of knowledge and skills and different types of
clinical experiences. The mentor's first
responsibility is to assess the present level of
knowledge and skill of the graduate. This
provides the basis for planning assignments
that expand the nurse's knowledge base and
allow the nurse to practice essential skills.
Nurses need to practice what they are learning;
one experience in caring for a patient or
performing a new skill is not enough to
become proficient. Opportunities to practice
skills and receive feedback facilitate learning in
clinical practice (Lofmark & Wikblad 2001).
One predominant stress reported by the
new graduates in this study was making
mistakes because of increased workload
and responsibilities. Graduates also viewed
this as a challenge to be met as they adapted
to the work setting. In planning patient
assignments, the mentor should gradually
increase workload and patient
responsibilities. Being available to help the
nurse in organizing care and in making
clinical judgments will provide the support
needed for graduates to meet the challenges
of beginning practice.
Two other strategies easily incorporated
into the mentor's role are: (1) meeting with
the new graduates periodically throughout
the day to answer questions; and (2) having a
`debriefing' session at the end of the day, for
discussion of problems encountered and
alternate ways of solving them. In these
discussions the mentor also can guide the
nurse in handling difficult situations that may
arise with patients and staff. These strategies,
though, are only effective with a consistent
mentor to whom the graduates can turn and
rely on during orientation. The lack of a
consistent preceptor was a stress identified by
the new graduates surveyed across all three
hospitals.
The next step in the process of teaching
new graduates is to guide nurses to acquire
essential knowledge and skills for practice
and to develop self-confidence. Guidance
involves teaching about diagnoses,
interventions, and other aspects of patient
care in which the graduate is unsure,
demonstrating new procedures and
techniques, questioning nurses to expand
their understanding of a clinical situation,
providing feedback and reinforcement, and
serving as a role model.
Interactions with staff
One of the most important conclusions that
can be drawn from this study is the
importance of the interactions and
communications that occur during orientation.
Graduates reported that when they had open
communication with the manager, preceptor,
and others, and when they viewed these
people as supporting them on the unit, this
interaction facilitated their learning and
development of self-confidence.
Along the same line, having to work with
`difficult' nurses and other personnel on the
unit was a stress for new graduates. This has
implications for identifying mentors and
matching them with graduates. Mentors
should be expert clinicians, have an
understanding of the role of the mentor
and how to teach, work well with others,
and be enthusiastic about their role as a
nurse. Strong interpersonal skills and
willingness to work with others are essential
Stresses and challenges for new graduates
& 2002 Published by Elsevier Science Ltd Nurse EducationToday (2002) 22, 225230 229
characteristics of an effective clinical teacher
(Gaberson & Oermann 1999).
Conclusions
Although the importance of establishing
supportive relationships with new graduates is
documented in the literature, this remains an
area in need of improvement. It is up to the
nurse manager, preceptor, and other
experienced nurses to work toward developing
trusting and caring relationships with new
nurses on the unit. A trusting and supportive
relationship between the mentor and
new graduate makes this learning less
stressful.
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