By Debra Wood, RN, contributor
Newly licensed nurses often encounter frustration with their new positions, citing unexpected situations, demanding assignments, a relentless pressure for speed and lack of respect, according to a new Robert Wood Johnson Foundation-funded study.
Lead author Linda Honan Pellico, Ph.D., APRN, was pleased with new nurses’ optimism that they will be able to improve their work environments.
“I wasn’t surprised with the widespread dissatisfaction with the work environment, but I was surprised by the optimism of this new cohort of registered nurses coming into acute care,” says lead author Linda Honan Pellico, Ph.D., APRN, assistant professor at the Yale University School of Nursing in New Haven, Connecticut. “They have this optimism that they can change the work environment. And if they were dissatisfied, they would leave. That is telling about the new nurses.”
The study provides insight into the reasons for reported turnover rates, which ranged from 13 to 70 percent for newly licensed registered nurses.
“Hospital administrators are going to have to take into account that this revolving door phenomenon is not helping them, and more importantly, not helping patient care,” Pellico said.
The paper, published July 27, 2009, in Nursing Outlook, outlines five themes elicited from responses to a 207-question survey completed by 612 newly licensed registered nurses in 34 states and the District of Columbia.
The themes include:
1. Colliding expectations, which describes conflicts between nurses’ views of nursing and the reality of caring for patients;
2. The need for speed;
3. You want too much, focusing on pressures and stress associated with their careers;
4. How dare you, outlining unacceptable communication patterns between providers; and
5. Change is on the horizon, with new nurses expressing hope that they can act as a new voice for change in nursing.
“Some of these issues are quite easily fixed, but some will have financial impact,” said Pellico, explaining that decreasing nurse to patient ratios will add cost but is a necessary step to reduce stress and improve the environment.
“This is a clarion call for hospitals to look at the work environment and understand if we don’t begin to heed their cries, we are going to lose them,” added Pellico, citing all of the employment opportunities beyond acute care that exist for nurses.
Geraldine (Polly) Bednash, PhD, RN, FAAN, CEO of AACN, indicated that changes in the student-to-RN transition contribute to new nurse dissatisfaction.
“They are not leaving the field; they are only changing jobs,” added Geraldine (Polly) Bednash, Ph.D., RN, FAAN, chief executive officer of the American Association of Colleges of Nursing (AACN). “These people are highly committed to nursing and are looking for the place that will give them the opportunity to express it the way they think it needs to be addressed.”
Many new nurses told survey takers they would prefer to work eight-hour days. Some called the 12-hour shifts dangerous.
Some nurses in the study told researchers that tasks in their first jobs do not reflect what they learned in nursing school. Many also expressed dissatisfaction with the lack of time they can spend with patients, while others felt their work was not appreciated by hospital physicians, administrators, and in some cases, more senior nurse managers.
New nurses commented that extended orientations and residency programs are helpful.
“The residency programs are absolutely essential,” Pellico said. “The residencies gave them time to develop clinical skills and a place to feel support. It bolstered their confidence and helped them with conflict resolution.”
Many hospitals have started offering residencies and found them very effective in decreasing turnover. Hospitals participating in the University HealthSystem Consortium (UHC)/AACN Nurse Residency Program have, collectively, a first-year 5.6 percent turnover rate.
“Hospitals willing to deliver structured residency programs are stating they value new nurses,” said JoAnn DelMonte, RN, MSN, supervisor of clinical entry programs and the graduate nurse residency program coordinator at the University of Colorado Hospital in Denver, which has placed novice nurses in the UHC/AACN residency program since 2002.
“Residency programs have become a mechanism to deal with much of the stress,” DelMonte added. “[New nurses] are well supported with monthly, cohorted sessions to receive mutual professional support and well-designed UHC curriculum.”
At the monthly meetings, new nurses can bring up concerns and issues they have confronted, and a professional facilitator will help them think critically about how to solve those problems and suggest resources to make it happen. The UHC curriculum includes stress management, communicating with physicians and time management, as well as clinical topics.
The University of Colorado Hospital enjoys a less than 0.2 percent turnover rate at one year for new graduates. It hires more than 100 new graduates each year.
“We have spectacular retention rates [with the residency program],” Bednash said.
In addition to residencies helping combat new nurse turnover, Pellico said that change also must occur at schools of nursing to better prepare nurses to work in acute-care settings. Survey respondents suggested students should spend eight hours at clinical sites, with more realistic nursepatient ratios.
Students in Yale’s accelerated program start off at six hours, but by the second semester they spend eight hours at the hospital.
Bednash said that while schools are trying to create learning experiences that reflect the work experience, it still might not seem real until the new graduate shoulders that new responsibility. Years ago when board exams were held twice annually, nurses moved into a general or graduate nurse role, during which they assumed limited responsibilities and staff nurses monitored them, creating a natural transition to full RN status. But now graduates can finish a program, take the NCLEX, and start working immediately as a registered nurse.
“It’s not just the learning experience; it’s how the work environment has changed,” Bednash said.
Even so, a number of institutions are creating new models of clinical education, Bednash added. For instance, the University of Portland in Oregon implemented a model called the dedicated educational unit. Students assigned to the unit have an intensive, ongoing experience, learning about the organization and working with mentors.
“They come out with a higher sense of competence, but it doesn’t mean they still don’t have to go through the transition, where they get into the job when they are really the nurse,” Bednash said.
She pointed out that schools should also help students learn how to communicate better with physicians and nurses, such as how to succinctly summarize the patient’s condition and what is needed for their care, and how to take a report.
“We delude ourselves into thinking these skill sets are natural abilities, and they are not,” Pellico said. “We can train people to improve them.”
AACN has built into its new standards for baccalaureate education the need to enhance a student’s ability to communicate with other members of the team.
Pellico also suggested that rather than educating physicians and nurses in silos, some type of joint programs could be developed, so clinicians learn how to work as part of a team from the start.
“We believe inter-professional education is a very important way to have all health professionals understand each other better,” Bednash said. “We know the absolute best care will be given through teams working together.”
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