You’ve spent four years in nursing school, reading, training and practicing. Then it happens. You graduate. Suddenly, someone else’s life is in your hands.
The transition from student nurse to practicing RN can seem abrupt, even after years of preparation. Many nursing educators believe it’s too sudden—and one reason why so many newly graduated nurses leave the profession after just a few years.
“If students don’t understand what a nurse does [in an actual workplace setting], they don’t know what to expect. They tend to burn out early and leave the profession,” says Connie Rowles, RN, DSN, CNNA, a clinical associate professor at Indiana University School of Nursing (IUSON) in Indianapolis.
Indeed, nurses are leaving the field at a record pace. A recent study conducted by Julie Sochalski, RN, PhD, of the University of Pennsylvania reveals that new nurses are abandoning the profession at much faster rates than they did just 10 years ago. Four percent of new female nurses drop out within four years of earning their RN licensure; for males, the figure is almost double (7.5%).
Making a smooth transition from the college campus to the “real world” of that first nursing job is difficult for everyone. But new graduates who are racial, ethnic or gender minorities often face unique transitional challenges that majority nurses are spared. In many parts of the country, new minority nurses entering the RN workforce may find that they are the only person or color, or the only man, on their unit or even an entire floor.
Shanae Monger, RN, BSN, a recent IUSON graduate who is African American, has experienced this situation firsthand. “Some people still assume that I am an assistant,” she says. “They ask me to get the nurse. That could be because of both my youth and my race. Either way, it’s their problem and I don’t let it get to me.”
This feeling of being “alone in a crowd” can not only cause minority nurses to burn out early in their careers but also prevent them from planning for future leadership roles, believes Marsha Tahquechi, RN, CNM, director of the Diversity Mentorship Program at Brigham and Women’s Hospital in Boston.
“Nursing in general does not have a very diverse workforce,” she notes. “This makes it harder to make the transition from student to professional. It can be a very stressful time when you’re joining an organization, and it’s complicated when others are unfamiliar with our cultural backgrounds. A lot of the problems minority nurses have to overcome can be seen in the fact that there’s not a lot of nurses from diverse backgrounds in hospital management.”
Tahquechi, an American Indian of Mohawk and Comanche descent, has had her own experiences working in culturally insensitive environments. Because her skin is fair, she says, people often assume that she is Hispanic or Caucasian.
“It’s very disheartening when everyone makes a general assumption about who you are in terms of your culture and background,” she adds. “That seems to happen less often when you have nurses of diverse backgrounds on the floor.”
Tahquechi encourages new nurses who are the only person of their race or ethnicity in their work group to seek support outside their immediate area, such as befriending nurses of color from other units and joining the local chapter of a minority nursing association. She also hopes that minority nurses will embrace their situation as an opportunity to educate others. “You can serve as a good resource for other nurses who may not be familiar your culture,” she says.
Virginia Hicks, RN, MSN, CLNC, an associate professor in the School of Nursing at historically black Grambling State University in Grambling, La., feels that new nurses of color who suddenly find themselves transitioning from college campuses where they were in the majority to workplaces where they are in the minority can sometimes lack the confidence and assertiveness of their white counterparts.
“Assertiveness ties in with self-confidence and it comes with more experience,” she advises. “Be assertive when seeking opportunities to develop strong clinical skills. Seek those out. Don’t be passive and wait on people to bring those opportunities to you.”
For men, moving from the co-ed world of college to the 95% female world of the nursing workforce presents its own special challenges.
“The biggest problem for males is just the pressure that some female nurses put on us,” says Martin Joplin, RN, MSN, NP-C, ARNP, a recent graduate of the MSN program at Case Western Reserve University in Cleveland. “There are still a lot of old-school nurses out there who think nursing should be a woman’s profession. They see a man on the floor and the first thing they say is, ‘I’m so glad you’re here. You can help me move or turn my patients.’”
Joplin is currently training in an emergency room to prepare him for working independently in a clinic in rural Kentucky. This is the second time he has experienced the “school work to real work” transition. The first came after he earned his BSN degree and secured his first job as an RN.
Joplin feels lucky that his first work experience was in an environment that was welcoming to men. “It was a very supportive environment,” he recalls. “The other nurses helped me a lot. When I had questions, they were very understanding.” He also had a male preceptor, someone with whom he could share a common perspective and interests. “I can’t say that it made the transition easier just because he was a man, but during the down time we could talk about football or baseball.”
Joplin encourages new male nurses to “make some good friendships with other guys at the facility.” He suggests becoming active in nursing professional organizations if guys are in short supply at your particular workplace. The important thing is to avoid the isolation that many male nurses feel.
“There’s nothing wrong with making friends with the women you work with,” he adds. “Some of my best friendships in nursing have been with female colleagues. You are spending eight or 12 hours a day together, so it’s much better if you get along.”
Men entering the RN workforce should also be prepared for the inevitable “heavy lifting” requests they will receive from female nurses. While it’s fine to be helpful, Joplin cautions, make sure that assisting other nurses in this way doesn’t cause a drop in the quality of care your own patients receive. “Don’t sell yourself out,” he advises. “Don’t be intimidated. You might be a new graduate, but you’re just as important to the facility as any other nurse.”
For education majors, the transition into the professional arena is handled a bit differently. New elementary and high school teachers face a total immersion period in a “real world” classroom before graduation: For several weeks, it’s just them and their students. Of course, veteran teachers are always nearby, ready to step in when a second grader gets a little rowdy or a fifth grader falls off the monkey bars.
Many nursing schools and health care employers feel that nurses deserve the same opportunities to test the waters before they’re thrown into the deep end, and are taking steps to create programs designed to better prepare new nursing graduates for the unfamiliar experience of working independently on understaffed units where chaos may be the norm.
Indiana University’s Connie Rowles oversees one such program, the Capstone Practicum course. The class was added to the curriculum about two years ago as the last step before IUSON nursing students hit the real world.
“The faculty wanted something that would help ease the transition from student to RN,” explains Rowles. “We felt that it was very important to give each student a realistic preview.”
The course was designed through a collaborative effort that included local hospitals, nurses and the college. Students are paired with a mentor or preceptor at the unit and facility of their choosing for four weeks, working a total of 112 hours. The student nurses work closely with their preceptors, taking on their schedules and shadowing them.
Shanae Monger, who took the Capstone Practicum last spring, says the only thing she would do to improve the course is to make it longer. She spent her practicum working in the emergency room at Indianapolis’ Children’s Hospital.
Monger likens the practicum to breaking the apron strings. “By the end of the four weeks, we were supposed to be able to do all the things we learned in school,” she remembers. “The goal was to reach the point where we could take care of patients on our own.”
For Rowles, watching the transformation as unsure students become confident nurses is rewarding. “At the beginning of the course, they feel like they’re not quite ready for it,” she says. “But midway through, they start gaining confidence and thinking ‘maybe I can do this.’ By the end, they are sure they can. It’s a very enabling and empowering course. Students are able to see their own competence and realize they know far more than they think they do.”
Since the practicum is relatively new, data on whether it is helping to reduce the burnout and dropout rates for newly minted nurses hasn’t been collected yet. But Rowles feels certain that the program will indeed make a difference. Students so far have given it rave reviews.
Today a growing number of health care employers realize that offering programs to help about-to-graduate nursing students transition into the workplace can do more than just increase retention rates for new nurses. They can also be powerful recruiting tools, particularly for hospitals that want to attract a culturally diverse nursing staff. Brigham and Women’s Hospital’s Diversity Mentorship Program, which pairs up minority nursing students with minority mentors, is one such transition program designed with multicultural recruitment in mind.
“Eighteen percent of the Boston-area population is made up of people of color,” explains Tahquechi. “The Diversity Mentorship Program has been very beneficial in helping us attract more nurses from diverse backgrounds, to reflect the diverse patient base we serve.”
Like the Capstone Practicum, Tahquechi’s program also revolves around one-on-one relationships between students and preceptors. “It’s almost like having a big sister or brother,” she says. “The mentor becomes someone that they can talk to.”
Students begin during the summer before their senior year of nursing school. After returning to school in the fall, they are often hired as patient care associates part-time or when they’re home for the holidays. Most participants go on to become full-time employees of Brigham and Women’s after graduation.
“The students get comfortable and want to stay here,” Tahquechi notes. “It’s not threatening. They don’t need to prove themselves. They’ve already created relationships.” Nine of the last completed program’s 10 participants are now employed at the hospital.
The students receive no college credit for participating in the mentorship program, but they usually watch their clinical skills—and their confidence—increase. “During the time they are here, they work with their mentors and are engaged in critical thinking, looking at care plans and learning to interpret physician orders,” Tahquechi says.
Many nursing educators believe that critical thinking is one of the hardest things to teach students in a classroom setting. As a result, many newly graduated nurses are thrust into the workplace with critical thinking skills that are not fully developed.
“Students tend to want everything to go step one, step two, step three when they are learning procedures,” says Hicks. “When they get out in the real world, they often get frustrated because situations don’t go the way they learned it in the book.”
Based on her Capstone experience, Monger feels that practica can help new nurses develop their critical thinking abilities, enabling them to become independent caregivers sooner and with more confidence. “My preceptor was someone I could go to [when I needed help],” she recalls, “and I was confident that I had someone to check my work. But she made me do my own critical thinking.”
Another common misconception that catches new nurses off-guard is the volume of patients under their care. “Students have such limited experience,” Hicks explains. “They have the false perception that they will have only one or two patients to care for. In the academic setting, it’s a learning environment, so the number of patients is limited. But it’s not that way on the job.”
As the old saying goes, there’s simply no substitute for experience.
“I would advise everyone to get some work experience on a unit, as a student nurse or as a nursing assistant,” suggests Monger, who worked as an assistant in the labor and delivery ward of Indiana University Hospital, the same unit where she ended up taking her first official job as an RN. “It will make you feel more comfortable. Things like your bedside manner become second nature. If you get that stuff down, you can concentrate more on your nursing skills when the ‘real’ time comes.”
A smooth transition into the nursing workforce also involves choosing the right employer to work for. When you’re shopping your skills around, don’t focus just on salary and benefits. Ask questions about the hospital’s orientation program and how committed the facility is to the success of new graduates and minority nurses.
Start with the length of the orientation and training program. Experts recommend a minimum of three months, 40 hours a week.
“Find out what opportunities are available for cross training,” Hicks adds. “Will you work in one unit or several? Will you work under the guidance of a preceptor or be thrown to the wolves?”
Although preceptorship programs are often very helpful in easing new nurses into the profession, the one-on-one format can have its drawbacks. “You have to have very strong preceptors to mold new nurses. Sometimes it’s better for new grads to work with a variety of nurses,” Hicks advises. “Unfortunately, some facilities have such large staffing shortages that they will put any nurse in the preceptor role.” The danger, she cautions, is that the novice nurse may pick up bad habits or hear too much negativity.
Being paired with a bad preceptor can be enough to cause a new nurse to reconsider his or her choice of a career. If you find yourself in this situation, says Hicks, you should notify your supervisor, or the person in charge of orientation, immediately. Be tactful but be honest.
Joplin thinks nursing grads interviewing for their first RN job shouldn’t just rely on information provided by the human resources department. Instead, try to talk to a variety of people who work at the hospital, including new hires if possible.
“I’ve heard people say that orientation was supposed to be six weeks but it was actually two,” he warns. “The facility was so short-staffed that they saw a warm body and couldn’t resist putting them to work immediately.”
Monger agrees that nurses entering the workforce need time to adjust. Your first year may be a blur of frustration, tears and aching feet. Things do get better, though.
During one of Monger’s first shifts after starting her first job, she was responsible for discharging three patients. At first, it was intimidating, but that changed quickly. “By the end of the day, I knew how to do it,” she says. “Once you do something the first time, you’ll begin feeling more comfortable and more confident.”