Ready or not

Clinicians and educators both need more realistic understanding of how prepared newly registered nurses are for practice. 

I fully agree with Debra Thoms’ article, “Transitions require support” (Nursing Review, April); transition to practice does indeed require support.

I also concur with Thoms’ argument that expecting a newly graduated RN, or one in a new area of practice, to function to the same level as someone who has been in an area for a period of time is at best unrealistic and at worst unfair.

It seems that, without a doubt, university education for RNs is here to stay. So all research into curriculum design, clinical learning environments, clinical practice and clinical competence enables greater understanding of the issues related to the nursing workforce and therefore better informs the debate over practice readiness.

Also, given the forecasted nursing shortage, the difficulties in accessing quality clinical placements and the need for fiscal responsibility, gaining a better understanding of the apparent tension between the health industry and universities in Australia over whether graduate RNs are practice ready is essential.

Endeavouring to contribute new knowledge to this debate, I am undertaking a doctoral study that aims to explore the understanding of nurse unit managers and bachelor of nursing program co-ordinators regarding newly graduated RNs’ practice readiness within the Australian healthcare and educational contexts. This study is significant, given the differing opinions amongst clinicians and education providers in Australia as to whether graduate RNs are practice ready.

The transition period is widely acknowledged to be stressful and challenging for graduate RNs as they endeavour to consolidate their knowledge and gain mastery of clinical skills whilst attempting to integrate socially within the culture of a new working environment. This is the period when graduate RNs experience role conflict, as they encounter practice realities that challenge values they might have adopted as students.

The longstanding national and international debate relating to graduate RNs’ practice readiness and the perception of an inadequately prepared nursing workforce has been repeatedly discussed within nursing. In a paper published in Journal of Advanced Nursing titled, “Back to bedpans: the debates over preregistration nursing education in England”, Elizabeth Meerabeau acknowledges the debate in Australia and England regarding the move of nursing education into the tertiary sector and the practice readiness of graduate RNs and adds: “There is thus a tension between developing knowledge which has some academic currency, and work which has relevance to practice.”

With the award of registration, newly graduated RNs are declared to be practice ready as safe and competent practitioners, but notably, at a novice level. These graduates are expected to commence nursing practice at a beginning practitioner level in many different contexts.

In a paper published in the Journal of Advanced Nursing in 1980 titled, “The nature of nursing and the education of the nurse”, Dorothy Hall, the regional officer for nursing, World Health Organization Regional Office for Europe cautions against having unrealistic expectations of graduate RNs and suggests that nurses are the only professionals who are expected to be a completely finished product when they successfully complete their basic training.

Furthermore, a New Zealand study published in the Journal of Advanced Nursing titled, “Graduate nurses’ adjustment to initial employment: natural field work” found that there was no identifiable component of practice that was specific for the new graduate nurses within the hospital settings and that the demands of each situation dictated what responsibilities they might have on each shift.

Unrealistic expectations of graduate nurses were evident in many Australian studies, where dissatisfaction was noted with the level of preparation of nursing students and their ability to function as RNs who can hit the ground running with respect to nursing care provision upon graduation.

A seminal paper by Jennifer Greenwood Nurse Education Today titled, “Critique of the graduate nurse: an international perspective” found that nurses in the health sector generally complain that graduates have insufficient clinical and patient management skills and that universities are expected to produce RNs who can ‘hit the ground running’ with regards to nursing care provision. Nurses in the education sector, on the other hand, claimed to be preparing novice “rather than competent practitioners, who are critically reflective and committed to lifelong learning”, Greenwood reported.

In Australia, the bachelor of nursing curricula offer nursing students a minimum of 800 hours of clinical education (clinical placements) across a wide range of settings, such as acute care, aged care, primary care, mental health, rural and other settings. The impact of this part of the curricula needs to be explored, given that the majority of graduate RNs are initially employed within the acute care hospital environment based on the higher rate of job turnover there than in community or rural healthcare settings.

Given that the provision of nursing care has become highly specialised and technologically demanding, it is apparent that practice readiness is a complex and highly contextualised concept, which raises the question, ‘Practice ready for what?’

Is it realistic to expect new graduate nurses to be employed in any clinical context, including specialties such as intensive care, theatre, emergency departments, mental health and community services, as a novice practitioner?

Consider that the complexity of contemporary nursing practice, the ongoing changes in healthcare settings, the recent budget cuts and the widespread workforce reform across the country all contribute to the reduction in the level of support that health services are able or willing to afford graduates after employment.

Even though it’s widely accepted that education providers, healthcare services and regulatory bodies all play a major role in preparing graduate RNs, proposing a national transition support framework by the ACN, where all stakeholders have an equal voice, is necessary and timely.

However, for this framework to be effective, its architects first need to consider defining the graduate identity, to ensure that clinicians, employers and educators’ expectations of graduate RNs remain reasonable and realistic. Furthermore, this framework needs to work towards diminishing the delineation of educational responsibilities, in which the education sector is mainly responsible for the pre-registration component and the health sector takes over for the post-registration component, which includes the transition of new graduates into the nursing workforce.

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