experiences and learning during a graduate nurse program

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Experiences and learning during a graduate

nurse program: an examination using a focus

group approach

Lisa G. McKennaa,*, Campbell Greenb,1

a School of Nursing, Monash University, Peninsula Campus, McMahons Road, Frankston, Vic. 3199,

Australiab Peninsula Private Hospital, Frankston, Vic. 3199, Australia

Accepted 20 January 2004

Summary The graduate nurse year requires individuals to make a huge transitionfrom university student to registered nurse as part of the health care workforce.New graduates experience steep learning curves throughout the first year ofprofessional practice. This study sought to explore experiences and learningoccurring throughout the graduate nurse program for a group of seven new nurse

graduates. Focus group interviews were conducted at six months and 12 months intothe program using the same set of guiding questions. The first interview highlightedthat graduates early in the graduate year were internalised, concentrating on theirown survival in managing workloads, facing practice realities and coming to termswith themselves as nurses. Learning was primarily about survival strategies andperforming tasks. By the second interview, graduates were much less focussed onthemselves. They understood their place in the health care team, had gainedconfidence in their relationships, and were showing concern for the next graduatesarriving. Learning at this stage involved more higher order skills, including criticalthinking.

c 2004 Elsevier Ltd. All rights reserved.

KEYWORDSGraduate nurse;Focus group;Practice realities;Learning;

Experiences;Identity development

Introduction

The graduate nurse year sees individuals making thetransition from university student to registerednurse as part of an institutions workforce. This

transition involves significant personal and profes-sional growth. Experiences of new graduates can befear-provoking or satisfying depending on a range offactors including the degree to which the individualis provided with ongoing support and encourage-ment. Many nurses actually leave the profession inthe first 12 months following graduation (Com-monwealth of Australia, 2002; Owens et al., 2001).Graduate nurse programs have been developed bymany Australian hospitals to assist with transitionprocesses by providing supported environments and

* Corresponding author. Tel.: +61-3-9904-4352; fax: +61-3-9904-4655.

E-mail addresses: [email protected],[email protected].

1 Tel.: +61-3-9788-3466; fax: +61-3-9789-4124.

1471-5953/$ - see front matter c 2004 Elsevier Ltd. All rights reserved.doi:10.1016/j.nepr.2004.01.004

Nurse Education in Practice (2004) 4, 258263

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educational opportunities but vary in delivery(Commonwealth of Australia, 2002).

Literature review

A significant body of literature exists around thenew graduate nurse. Some of this has surroundedconcern about the preparation of new graduatesto function effectively in the clinical environ-ment, including possessing undeveloped criticalthinking and problem solving skills (del Bueno,1994). Duchscher (2001) interviewed nurses fol-lowing their first six months as nurses. She sug-gested that new graduates apply a linear modelof thinking to their practice and focus on com-pleting tasks without thinking about the rationalefor their actions. Graduates have a strong de-pendency on experienced colleagues and do not

establish the fundamental independence thatgives them a sense of themselves as professionals(Duchscher, 2001).

New graduate role

The move into the role of new graduate nurse hasbeen described as being one that evokes signifi-cant stress and can be overwhelming (Ellerton andGregor, 2003; Kelly, 1998; Thomka, 2001). Gerrish(2000) suggests that stress is contributed to withincreasing accountability for practice, ward and

patient management responsibilities and neces-sary proficiency of clinical skills. This may becompounded by applying knowledge from under-graduate courses into patient care along with ac-quisition of new skills (Oermann and Garvin,2002). As a consequence, reality shock is a com-mon occurrence for new graduates (Common-wealth of Australia, 2002; Winter-Collins andMcDaniel, 2000). Chang and Hancock (2003) foundthat graduates stress changed from role ambigu-ity early, to role overload later in the graduateyear. Through the period of being new graduates,nurses require ongoing support and guidance toensure continued development (Owens et al.,2001; Pigott, 2001). Furthermore, if there areinsufficient role models, graduates will endeavourto fit in and get tasks completed rather thanpractising their ideal conception of nursing (Wil-son and Startup, 1991).

Research indicates that often the process ofsocialization for new graduates occurs haphazardly(Gerrish, 2000; Thomka, 2001) and lacks consis-tency (Thomka, 2001). A study conducted byThomka (2001) found that new graduates expected

that they would be accepted and supported in theclinical environment, however, many found thattheir experiences did not meet their expectations.Some graduates reported being criticized openlyand in front of others. Furthermore, many reportedlittle consistency in how they were assisted to be-come socialized into the environment or their de-

velopment. Holland (1999) suggests it is unfair toexpect student nurses to articulate their learninginto accountable practice immediately upon reg-istration, and that the profession needs to take intoaccount the complexity of their new role as quali-fied nurses. Kelly (1998) examined how a group ofnew graduates adapted to the real world ex-trapolating six stages experienced: vulnerability,getting through the day, coping with moral dis-tress, alienation from self, coping with lostideals, and integration of new professional self-concept (p. 1137).

Graduate nurse programs

Many health care institutions offer graduate nurseprograms to assist the process of transition fromstudent to professional nurse. According to Clareet al. (1996), whilst graduates have met compe-tency requirements of their undergraduatecourses, they require orientation to the specificclinical context into which they are entering.Graduate nurse programs assist with developmentof clinical skills, increase familiarity with the

employing institution, as well as increasing self-confidence. Furthermore, these programs assistthe graduate to adapt to the work environmentworking as part of the team (Pigott, 2001). How-ever, these programs are not compulsory and varygreatly in content and support (Commonwealth ofAustralia, 2002).

Methodology

This paper reports on a small qualitative study thatwas designed to provide understanding around theexperiences of new graduate nurses in their firstyear of professional practice. Specifically, it soughtto identify sources and types of learning and chal-lenges facing new graduates, as well as identifypeople and resources that are beneficial to newgraduates. It was anticipated that findings from thestudy could assist with informing development offuture graduate nurse programs, assisting to ensurethat graduates needs are addressed at an optimallevel.

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Focus groups were chosen as an appropriate datacollection tool for this study as they bring togetherpeople with some similarities to allow the emer-gence and investigation of trends (Krueger, 1994),identification of key issues, insights into experi-ences and perspectives (Jackson, 1998). This ap-proach allowed for issues arising to be explored

among the group. In order to identify if graduatesexperiences changed during the program, it wasdecided to interview new graduates at two stagesduring their program, that is, at six months into theprogram, and again at the end.

The study sample was chosen using purposivesampling from a group of nurses almost six monthsinto their graduate nurse program across one groupof hospitals. After an introduction to the project,potential participants were invited to participateand provided with written documentation aboutthe study, including their right to withdraw at anytime. A total of seven individuals consented toparticipate. This number was considered appro-priate for effective focus groups, as 610 people isconsidered optimal (Krueger, 1994).

Formal ethical clearance was given by the rele-vant university ethics committee, and written ap-proval given by the Director of Nursing at thehospital as no formal ethics committee was inplace there. Strategies were put in place to ensureconfidentiality of individuals contributions. Par-ticipants were provided with pseudonyms to pro-tect their identities in the transcribed interviews.The second researcher, who also conducted the

graduate program, was not involved in the focusgroups, and worked only with the transcripts withpseudonyms. In addition, participants were re-minded prior to the commencement of each focusgroup about the need to protect each othersconfidentiality outside of the group.

A mutually agreeable time was chosen for eachof the focus groups within allocated study days inthe graduate nurse program. A series of questionswas developed, guided by available literature andpersonal experience, to guide the focus groups(see Appendix). These questions were the same forboth focus group sessions which allowed for somecomparisons across time to be made. Focus groupswere audio taped, transcribed verbatim and con-tent analysis performed. Transcripts were initiallyread and significant statements were removedindependently by both researchers. From these,meanings were developed and then clustered intothemes according to frequency and intensity(Neuman, 1997). The independent findings werethen compared by both researchers, and finallywith the original transcripts for validation of thefindings.

Findings

From the two focus group interviews it becameclear to the researchers that experiences andlearning of participants leading up to each inter-view were significantly different. In the first sixmonths of the graduate program, participants

appeared focussed on internal issues surroundingtheir clinical practice, personal identity and cop-ing strategies. Despite questioning about theirlearning, the focus was largely on survival and itbecame clear that learning had been limited tothis point. By the second interview participantsfocuses had externalised. They displayed the de-velopment of focus on others, including patients,the health care team and on extending theirlearning.

Focus group one: focussing on self

Working on clinical skills

A focus on the performance of technical skillsemerged in the first focus group. Being expected toperform clinical skills for the first time as a regis-tered nurse was described as fear-provoking and anarea focused on for mastery during the first sixmonths, eventually eliciting a sense of satisfactionas suggested by Sam:

Ive finally come to terms with IVs and antibiotics, flush-ing things and knowing when things are appropriate to

mix and when theyre not appropriate to mix and thatwas my biggest fear. . .most of the time I feel comfort-able with that. (Sam)

The need to master clinical skills included someskills that had not been taught in university coursesbut were expected in the clinical setting alsoformed part of the learning experience, an issueraised by Margaret:

. . .things like. . .doing male catheterisations we werenttaught. Well its really good to be able to go at the endof the day and say I did that. . .(Margaret)

Learning for graduates up to this stage heavily

involved learning to develop routines and manageallocated workloads. This at times meant not pro-viding time for addressing patients needs for in-formation. Sam and Paula both described beingaware of this:

Ive got a routine happening but also time managementsbeen an issue really because youve got to be preparedand ready to go so I think thats the biggest thing Ivelearnt since Ive been here. (Sam)

Sometimes you feel rude. You just want to run in theroom and do their obs and just run out again. And some

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of them just want to talk or ask you a question and youjust dont have time to do or you might give up the timecause you think I will stay here and talk to them and thenyou just fall behind even more. Thats always a hard bal-ancing act. (Paula)

Overall, learning was seen by participants to bedifferent from that which they had undertaken atuniversity. In this setting learning was more prac-tice-oriented and related to repeated skills prac-tice as highlighted by Rachel:

Its a different type of learning. I began with the antibiot-ics what to mix with and all that so I became very goodwith all that. (Rachel)

Facing realities of practice

Realities of practice emerged in many contexts inthe first focus group interview. Participants ex-pressed that they were just starting to understandwhat nursing was actually about something their

university courses had not provided. For example,Paula suggested:

Ive learnt what it really is to be a nurse. I dont think uniever prepared me for it, just actually working and nowIve got a better idea of what Im expected to do. I neverknew what it was like. (Paula)

Learning intricacies of the particular practicesetting also emerged as participants sought to un-derstand their employing institution and enhancetheir survival within it. This needed revisitingwhenever a new clinical rotation occurred or, asindicated by Rachel, on moving from night shift to

day shift:

My biggest fear was who to go to and who to contact andbecause I started with night duty for three months andIve just gone onto days and lates for the last three. . .Im just relearning everything. (Rachel)

Personal identity

Interestingly, at this stage participants were grap-pling with the notion that they were in fact nurses.Participants saw themselves as graduates first, andas nurses second. This perspective provided them

with security in being able to justify any lack ofknowledge or skill in the clinical area, as high-lighted by Paula, Sam and Rachel:

Its your year to ask questions and be dumb and. . .(Paula)

Make mistakes. Its all part of learning, all part of learn-ing. . .cause they know youre a graduate. You feel a bitsafer. (Sam)

After studying for three years, it took me a while to getover the fact that Im not a student anymore, Im a grad.I think it will take me a while to get over the fact thatnext year I wont be a grad anymore. (Rachel)

Coping mechanisms

There was evidence that participants up to thisinterview had developed coping strategies to assisttheir survival in their workplaces. Caroline spoke ofhow she managed knowledge deficits when patientsasked her questions:

Because they ask you about their procedure. You eventu-

ally get to know a bit about it to inform patients. Yourebluffing your way through it, being quiet. (Caroline)

Focus group two: refocussing on the biggerpicture

The second focus group interview revealed signifi-cant changes in the graduates approaches tothemselves and their places within the institution.Unlike the first interview, focus was externalisedtowards patients, the health care team and ex-tension of learning. Participants emphasis had

shifted to higher order thinking issues and self-actualisation.

Focussing on patient care

The development of nursepatient relationshipswas a significant area of which participants weremuch more aware. They described being able tofocus on patients and their conditions and to applytheir assessment skills, rather than worry abouttheir own performance. For example, Margaretindicated that:

Youbecomemore comfortablewith situations too.You can

walkintoaroomandnothavetoworryamIdoingthisright.You use your assessment skills and say well this is whatswrong with this patient and Im going to do somethingabout it and not have to think am I doing the right thingfor this patient. (Margaret)

Increased control over technical aspects of workresulted in increased awareness of patients needs.Greater emphasis was seen to be becoming placedon holistic care, including psychological needs ofpatients, as described by Margaret:

Because youve got your mechanical things under wrapdoesnt take two hours to do a dressing. Youve got moretime to sit down and discuss the psychological issues with

patients, find out whats happening for that patient. . .

You learn to talk while you are doing things. (Margaret)

Personal and professional development

This interview also revealed a shift in participantsawareness of their own personal and professionaldevelopment. It was evident that participants atthis point recognised that they were not sole prac-titioners but that they were part of a team. Theirperceptions of themselves were higher than earlier,and they felt much less subordinate than in the



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earlier interview. There was an indication of movingaway from seeing themselves as graduates and nowas nurses. Caroline identified making such as shift:

Its more about team work now. You see yourselves as al-most an equal. (Caroline)

The ability to use their assertiveness was an-

other aspect of professional growth that becameevident at this stage. Where in the first interviewparticipants felt that they needed to manage situ-ations on their own for fear of failure, they nowfelt comfortable enough to ask for assistance whenthey recognised reaching their limitations, asChristy outlined:

One of the things that Ive found is to be able to be asser-tive and say to people look I cant handle this. Youre notgoing to do this to me and Im not going to take this pa-tient. . .You get more confidence in saying to people look Ireally need a hand. Youve got to come and help me nowwhereas before it was, I dont know whether I should. I

dont really want to ask cause its like Im failing. . .

(Christy)

One of the significant areas that emerged at thisstage was the growth in professional esteem andrealising they themselves may have valuableknowledge and experience to share with others.This indicated a sense of acceptance into the pro-fessional nursing context. Sam highlighted thisthrough an example of herself being asked ques-tions by other nurses:

. . .you find people come and ask you questions what doyou think I should do with this?. . . Whether or not you

can give them the answers or nots another thing but theystill come and ask you whereas six months ago theywouldnt have cause you looked like you were flounder-ing. (Sam)

It also emerged that participants recognisedtheir value in developing future nurses, especiallythe roles that they might play in assisting thetransition of new graduates to the workplace.Margaret spoke about how her own experiencesmay assist the new group of graduates:

I think you can empathise a lot more with them becauseyou think gee I was there twelve months ago. I know ex-actly how you feel and makes you want to help them be-cause you dont want them to go through the samestresses that you went through bashing your head againsta brick wall all the time. (Margaret)

Discussion

This study revealed differences in learning and ex-periences at two randomly selected points in agraduate year. These relate only to one group of new

graduates and their experiences and as such cannotbe readily generalised to all graduates, however, thefindings do add support to the existing body ofknowledge around new nurse graduates and theirexperiences. The outcomes suggest that there aredevelopmental stages through which new graduatesprogress. Similar to findings of previous studies

(Kelly, 1998; Thomka, 2001), the graduates in thisstudy experienced stress and fear early in their pro-gram. In these early stages, graduates concerns arearound their performance with clinical skills, facingrealities of practice and coping. There is support forthe work of Duchscher (2001) in that graduates ap-pear to focus on task completion without reallyconsidering rationale. By the second half of the year,theyhadbeguntobecomemoreopenandbetterableto acknowledge external influences through greaterapplication of higher order processes such as criticalthinking. Similar to findings by Duchscher (2001)nurses at six months following graduation focused onthemselves, rather than on patients.

The new graduates in the study group perceivedthemselves as a sub-set of nursing identifying asgraduates first, and as nurses second. They wereable to seek support for any deficiencies in skill orknowledge in doing this. The development of pro-fessional identity for new graduates does appear totake some time to develop and supports Chang andHancocks (2003) finding that new graduates earlyin the year experience role ambiguity. This currentgroup questioned their role and found it difficult toidentify early with nursing professionals.

This study involved only two periods of timechosen at random by the researchers. Other studieshave employed similar approaches at three months(Ellerton and Gregor, 2003) and at six months(Duchscher, 2001) into graduate years. Furtherstudies on a larger scale, and employing differentmethodology, are indicated to articulate greaterdetail about what new graduates experience and toassist with identifying specific types of supportrequired. Understanding the graduate nurse be-yond the six month period is more limited andwould benefit from further research. Increasedunderstanding of what new graduates experiencewill allow for more appropriate support structuresto be developed and tailoring of graduate programstowards the changing needs of new graduates bynurse educators.

Conclusion

The graduate year is one of great development butcan provoke stress and uncertainty in new graduate

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nurses. The individual must adjust from universityto the workplace, in so making a transition fromthe role of student to registered nurse. This in-volves a period of extensive growth, both profes-sionally and personally. Ongoing support is requiredto ease the transition. This focus group study hasidentified different types of learning and experi-

ences that occur during the graduate year, alongwith types of support that may assist with thetransitional processes taking place.

Acknowledgements

The authors thank the nurses who participated inthe focus groups and allowed us to explore personalaspects relating to experiences and learning duringtheir graduate nurse program.

Appendix A

References

ChangE., Hancock,K., 2003.Rolestress androleambiguityin newnursing graduates. Nursing and Health Sciences 5, 155163.

Clare J., Longson D., Glover P., Schubert S., Hofmeyer,A., 1996. From university student to registered nurse:the perennial enigma. Contemporary Nurse 5, 169176.

Commonwealth of Australia, 2002. The Patient Profession:Time for Action, Report on the Inquiry into Nursing.Available from [Retrived 20/6/03].

del Bueno, D.J., 1994. Why cant new grads think like nurses?

Nurse Educator 19, 911.Duchscher, J.E.B., 2001. Out in the real world: newly graduated

nurses in acute care speak out. Journal of Nursing Adminis-tration 31, 426429.

Ellerton M., Gregor, F., 2003. A study of transition: the newnurse graduate at 3 months. Journal of Continuing Educationin Nursing 34, 103107.

Gerrish, K., 2000. Still fumbling along? A comparative study ofthe newly qualified nurses perception of the transition fromstudent to qualified nurse. Journal of Advanced Nursing 32,473480.

Holland, K., 1999. A journey to becoming: the student nurse intransition. Journal of Advanced Nursing 29, 229236.

Jackson, P., 1998. Focus group interviews as a methodology.Nurse Researcher 6, 7284.

Kelly, B., 1998. Preserving moral integrity: a follow-up studywith new graduate nurses. Journal of Advanced Nursing 28,11341145.

Krueger, R.A., 1994. Focus Groups: A Practical Guide for AppliedResearch. Sage, California.

Neuman, W.L., 1997. Social Research Methods: Qualita-tive and Quantitative Approaches. Allyn & Bacon,Boston.

Oermann, M.H., Garvin, M.F., 2002. Stresses and challenges fornew graduates in hospitals. Nurse Education Today.Doi:10.1054/nedt.2001.0695.

Owens D.L., Turjanica M.A., Scanion M.W., Sandhusen A.E.,Williamson M., Hebert C., Facteau, L., 2001. New graduateRN internship program: a collaborative approach for system-wide integration. Journal for Nurses in Staff Development 17,

144150.Pigott, H., 2001. Facing reality: the transition from

student to graduate nurse. Australian Nursing Journal8, 2426.

Thomka, L.A., 2001. Graduate nurses experiences of interac-tions with professional nursing staff during transition to theprofessional role. The Journal of Continuing Education inNursing 32, 1519.

Wilson A., Startup, R., 1991. Nurse socialization: issuesand problems. Journal of Advanced Nursing 16,14781486.

Winter-Collins A., McDaniel, A., 2000. Sense of belonging andnew graduate job satisfaction. Journal of Nurses in StaffDevelopment 16, 103111.

Guiding questions for both focus groups

How would you describe your learning over thepast three months?

What have been the major areas of learning inthis time?

What have been the sources of that learning?What have been the most satisfying elements for

you to date?What have been the most challenging or difficult

aspects to date?What types of people have been the most

influential during this time?How do you perceive yourself as a registered

nurse?

http://www.aph.gov.au/senate/committee/clac_ctte/nursing/report/contents.htmhttp://www.aph.gov.au/senate/committee/clac_ctte/nursing/report/contents.htmhttp://dx.doi.org/10.1054/nedt.2001.0695http://dx.doi.org/10.1054/nedt.2001.0695http://www.aph.gov.au/senate/committee/clac_ctte/nursing/report/contents.htmhttp://www.aph.gov.au/senate/committee/clac_ctte/nursing/report/contents.htm

experiences and learning during a graduate nurse program

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