In recent years, many countries have faced serious nursing staff shortages, representing a major global healthcare challenge (Buerhaus et al, 2009; International Council of Nurses, 2019). The same problem has occurred in the UK (NHS Employers, 2015), where staff shortages mean that health professionals are put under increasing pressure to deliver the high quality care the public has a right to expect. In the UK alone, there is a shortfall of over 10% of the workforce and the Nursing and Midwifery Council (NMC) reported that more nurses are leaving the profession than are registering to practise: between 2016 and 2017, 27% more registrants left than joined (NMC, 2017).
Likewise, according to Laschinger and Read (2016), in Canada nearly 60% of nurses change or leave the profession within 2 years of employment and 25% of US nurses leave a position within the first year of practice (Spector, 2015). While the main causes of nurses leaving the profession are unknown, it has been shown that poor nursing environments, lack of mentoring and ‘reality shock’ (Kumaran and Carney, 2014) can often contribute to snowballing attrition rates (Flinkman and Salanterä, 2015; Kenny et al, 2016; Lo et al, 2018).
This article explores the different preceptorship experienced by the newly qualified nurse (NQN) and how employers can develop and improve on this experience and support the NQN to remain in employment.
The newly qualified nurse
It is estimated that approximately 60% of the nursing workforce consists of NQNs (Whitehead et al, 2013). The Department of Health (DH) referred to a ‘newly registered practitioner’ as a ‘nurse, midwife or AHP [allied health professional] who is entering employment in England for the first time following professional registration’ (DH, 2010:6), which would be registration with the NMC or the Health and Care Professionals Council. Newton and McKenna (2007) and Duchscher (2008) noted that after completing a pre-registration nursing education NQNs are enthusiastic about beginning their new role as a registered nurse.
However, in spite of their enthusiasm, the first few months in their new role can be stressful and challenging. Higgins et al (2010) described this period as transition, when the change from being a nursing student to working as a staff nurse takes place. Duchscher (2008) pointed out that NQNs undergo a difficult period of transition in their first year of employment, going from nursing student without full responsibilities to registered nurse with full accountability for their actions, introducing them to harsh reality.
Transition
Transition was initially described by Arnold van Gennep in 1909. He defined it as the potentially threatening and harmful stage between social statuses, where the individual no longer belonged to his or her previous status but had not yet completed passage to the next (van Gennep, 2019). Although this definition is both old and generalised, it remains relevant today and to nursing. Many international authors have highlighted the transition period as a difficult time for NQNs.
For example, Bridges and Bridges (2017) and Higgins et al (2010) defined transition as a period of changes encompassing certain difficulties. Bridges and Bridges (2017) saw it as a psychological process whereby NQNs undergo a difficult period to come to terms with change. Higgins et al (2010) considered the transition process ‘ill and lacking clearness’, which generates potential conflict and obscures the boundaries between nurses and healthcare work; it can be a disillusioning and discouraging period (Kaihlanen et al, 2013). Stressful transition results in a high number of NQNs leaving the profession in their first year, leading to a vicious cycle of staff shortages and poor management of patient care (Health Education England, 2016). Duchscher (2008) highlighted that during the transition period new graduates experience fear of incompetence, of harming the patient, of failing to provide holistic person-centred care and of responsibility; the consequent reality shock can prompt some to leave the profession (Kumaran and Carney, 2014).
Reality shock theory was initially identified by Kramer (1974), who devised the term when describing the transition period between school-bred values and work-world values for baccalaureate graduates in the USA. The author emphasised that reality shock generally resulted from a theory–practice gap. This gap was also identified in the UK when nursing education was moved from hospitals to universities in the 1980s due to concerns over the effectiveness of apprenticeship-style nursing training in a rapidly changing and expanding healthcare system (Francis and Humphreys, 1998). In the 1980s, following the publication of a report on nursing education (Rye, 1985) for the Royal College of Nursing (RCN) that sought to address the theory-practice gap, there was a movement towards the reorganisation of pre-registration courses for nurses.
Pre-registration education in nursing plays a major role in the NQN transition period. Today, a nursing degree in the UK is a 3-year programme, of which 50% comprises theoretical classes at a university and 50% is made up of clinical placements to acquire the proficiencies needed to meet the criteria for NMC registration (NMC, 2018a). The NMC Code (2018b) states that the curriculum must provide graduates with the competence required for registration, defined as a holistic concept for nurses divided into four main areas, namely prioritising people, practising effectively, preserving safety, and promoting professionalism and trust. The NMC (2018a) standards of proficiency for registered nurses state that a degree education must provide nurses with the theoretical knowledge and skills required to deliver and manage person-centred care and also the proficiencies to equip NQNs with the underpinning knowledge and skills required for their role in providing and evaluating person-centred care.
Theory–practice gap
However, despite this, a critical review conducted by Freeling and Parker (2015) found that NQNs are inadequately prepared for practice by academic programmes. Glen (2009) had the same view on education when he stated that pre-registration education is inadequate because NQNs feel unprepared for their new role. This author also found that higher academic levels and increasing academic workload resulted in academic overload, thereby increasing the theory–practice gap.
Hegarty et al (2015), meanwhile, raised concerns about clinical placement, as NQNs stated that specific needs were not being met, meaning they were not prepared for practice in real life. These findings were also identified by Hickey (2009), who noted that clinical experiences during the education programme did not prepare NQNs adequately for the work environment.
Hickey (2009) found that the most common areas of weakness among NQNs in the transition period are assessment skills, time management, teamwork and communication, while Chernomas et al (2010) highlighted organisation, delegation and time-management skills as significant challenges. A study by Hartigan et al (2010) reported NQNs experiencing a lack of confidence in clinical decision making, despite often judging situations correctly. Clark and Holmes (2007) highlighted increased responsibility and accountability as a major stressor, describing how NQNs were often pushed to take on greater responsibility than that for which they had been prepared. The NMC Code (2018b) states that NQNs must practise within the limits of their training, education and competence, and increased levels of stress can affect the management of person-centred care.
Marquis and Huston (2017) defined the management of patient care as a decision-making, problem-solving and critical-thinking mechanism that includes learnt skills that improve with practice. Management and competence are emphasised by the NMC Code and NMC standards of proficiency for registered nurses (NMC, 2018a; 2018b). Following the Francis (2013) public inquiry report into major failings in care at Mid Staffordshire NHS Foundation Trust, management of person-centred care once again became a priority, focusing on dignity, compassion, respect and duty of candour. A few years later, a Care Quality Commission (CQC) report, stated that only 55% of patients rated NHS services as good (CQC, 2017).
Currie et al (2009) has highlighted that, although undergraduate nursing students are aware of the concepts of person-centred care; in reality they experience a lack of competence in delivering safe, high-quality care.
Support for the newly qualified nurses
Miller and Blackman (2003) and Edwards et al (2015) noted that appropriate support can reduce the difficulties experienced by NQNs and help with their transition, building confidence, improving competency and increasing understanding of their role, which will lead to a more positive experience, smoother acceptance within the nursing team and improvement in the management of patient care. Hollywood (2011), however, argued that limited or no support can benefit NQNs because ‘being thrown in at the deep end’ can boost independence and confidence, leading to greater coping and motivating NQNs to increase their knowledge and skills. However, the RCN (2014) highlighted that poor support or the lack of support are not acceptable because they have negative effects on patient care, reducing the quality of care delivery and increasing the risk of harm to patients.
The various support strategies that have been implemented worldwide to improve the transition process have been explored in the literature, which has included:
Each of these models or programmes provides a different approach to supporting NQNs (Harrison-White and Simons, 2013). Residency programmes provide 1 year of comprehensive orientation to prepare NQNs for their career (Lin et al, 2014) and graduate nurse orientation programmes of 1–20 weeks are designed to facilitate the integration of skills and knowledge in practice (Rush et al, 2013). Interprofessional education aims to enable nursing students to become more collaborative-ready for practice by the time they start working. It involves engagement in learning with and from other health professionals to enhance the quality of care and improve collaboration (Pullon et al, 2016). The purpose of internship/residency programmes (6–8 weeks or 6 months–1 year) is to connect academic preparation with the demands of clinical practice (Kowalski and Cross, 2010). In simulation-based graduate programmes NQNs have the opportunity to develop their knowledge and skills in a safe environment via exposure to patient scenarios they are likely to encounter in their career (Cant and Cooper, 2010; Traynor et al 2010). According to Komaratat and Oumtanee (2009) mentorships/preceptorships aim to increase knowledge and skills and build confidence with the assistance of a preceptor or mentor.
Evaluation of these transition programmes has found significant improvements in the confidence and competence levels of NQNs (Park and Jones, 2010; Ulrich et al, 2010); Pullon et al (2016) noted the development and improvement of knowledge. Krugman et al (2006) highlighted reduced stress levels and Beyea et al (2010) a readiness for practice. Meanwhile, Edwards et al (2015) observed that the support strategy undertaken is less important than the focus and investment in the strategy that eases NQN transition.
Preceptorship programmes
In the UK, preceptorship programmes commenced in 1990 after being recommended by the UK Central Council for Nursing Midwifery and Health Visiting (UKCC) (1986) and, currently, the NMC (2006) strongly suggests that all ‘new registrants’ participate in a period of preceptorship commencing employment because it recognises that nurses need to be more independent, autonomous and innovative.
However, preceptorship programmes vary from country to country. In the USA, several approaches have been taken to improve the transitioning experience for NQNs. Many hospitals have developed internship programmes to ease the transition from student to staff nurse, and evaluations have shown that such programmes have enhanced the confidence of NQNs in clinical skills, communication with patients and overall teamwork, which contribute to the overall success of graduate nurses developing as competent practitioners (Steen et al, 2011).
In Australia, the enhanced transition programme comprises one-to-one preceptorship along with three rotated clinical areas and specialties (Christensen et al, 2016). A one-to-one preceptorship programme also exists in Canada and preceptors and preceptees are matched by their learning style in order to improved job satisfaction (Willemson-McBride, 2010; Ke et al, 2017).
However, not only does preceptorship differ globally, but even within the UK there are variants to the model. For example, Scotland has the Flying Start NHS programme (Banks et al, 2011) to support NQNs during the challenging time of transition, develop their skills and improve confidence levels. The programme is web based and includes 10 learning units that NQNs are expected to complete within 1 year of registration, which also involves the allocation of a preceptor who goes through the programme and activities with the NQN (Banks et al, 2011). In England, the preceptorship framework has adapted the Flying Start programme to be used alongside DH guidelines that include engaging in a variety of activities in the first 6-12 months: these include work-based learning, web-based learning, organisationally based learning, reflective practice and preceptor support (DH, 2010). Trusts in Northern Ireland have also adapted and developed a preceptorship programme (Department of Health, Social Services and Public Safety. (DHSSPS), 2011; McCusker, 2013).
In England, the DH (2010:11) defined preceptorship as ‘a period of structured transition for the newly registered practitioner during which he or she will be supported by a preceptor, to develop their confidence as an autonomous professional, refine skills, values and behaviours and to continue on their journey of life-long learning’. According to the NMC (2006), preceptors should have at least 1 year's experience, as well as a teaching qualification. Preceptorship provides support and guidance to NQNs to become more confident practitioners who can practise in line with NMC standards. The NMC (2006) strongly recommends that all NQNs should have a formal period of preceptorship of 4–6 months depending on individual need and local circumstances.
One of the main goals of preceptorships is building up confidence and competence levels to accomplish the effective management of patient care and the further development of a practitioner's knowledge and skills (Bukhari, 2011). This underscores the findings of studies by Hickey (2009) and Whitehead and Holmes (2011), who suggested that confidence can be developed through preceptorship. Each of these goals appear to be important for NQNs (Lewis and McGowan, 2015). In addition, preceptorship has been found to reduce nursing shortages, promote staff retention and decrease staff turnover (Whitehead et al, 2013).
Many authors have highlighted improvements in NQN competence, confidence and stress levels with preceptorship. Marks-Maran et al (2013) stated that preceptorship can facilitate the transition of NQNs into their new roles. Jonsen et al (2013) showed that preceptorship support had a beneficial effect on NQNs, facilitating a positive working environment that promoted feelings of security, enhanced confidence and reduced stress. The systematic reviews on preceptorship by Missen et al (2014) and Ke et al (2017) noted that it improves retention rates and job satisfaction, reduces stress and anxiety, improves critical thinking and significantly increases the confidence and competence levels of NQNs, resulting in optimal management of patient-centred care.
Although professional bodies have guidelines and frameworks on preceptorship and the DHSSPS (2011) states that such programmes should be free of barriers, in real life preceptorship can be challenging. Despite many positive reviews, the preceptorship strategy has been open to criticism. Romyn et al (2009) found that preceptors are exposed to heavy workloads, excessive overtime, inflexible scheduling, a lack of leadership and limited access to professional development opportunities.
These findings have been corroborated by the work of Robinson and Griffiths (2009), Higgins et al (2010), McCarthy and Murphy (2010) and Whitehead at al (2016). The authors revealed that minimal guidance was given to preceptors for their role, leaving them uncertain as to what was expected of them. McCarthy and Murphy (2010) highlighted that nurses who undertake preceptorship roles have a full clinical workload in addition to their mentoring roles, resulting in preceptors often being reluctant volunteers. Whitehead at al (2016) noted that nurses are often simply ‘chosen’ or ‘asked’ to be preceptors. Carlson et al (2010) found that staff showed signs of stress and anxiety related to time shortages due to their full clinical workload. Research-based findings have highlighted that preceptors appear to be inadequately prepared for the role (Gleeson, 2008).
Robinson and Griffiths (2009); Higgins et al (2010) have pointed out that many NQNs did not receive preceptorship support even when they were allocated to preceptors.
Consequently, there is an argument that preceptorship guidelines and frameworks need to be reviewed and developed further. The importance of further developing current preceptorship programmes for newly registered nurses has been highlighted in two documents: Raising the Bar—Shape of Caring (Willis, 2015) and Quality 2020: A Ten-Year Strategy (DHSSPS, 2011) to protect and improve quality in health and social care in Northern Ireland.
Conclusion
Negative experiences during the transition period can delay the time that NQNs take to achieve their full potential in delivering patient-centred care. Strong supportive strategies such as preceptorship are therefore vital. Properly resourced and organised preceptorship programmes are a positive and essential experience for NQNs. However, employers could improve the preceptorship frameworks, management support and educational preparation for preceptors, and provide protected time for preceptors and preceptees. For example, there are inconsistencies within preceptorship programmes and inconsistencies regarding supernumerary time; in addition, the allocation of qualified preceptors can prove problematic for many NQNs.
There is a clear need for more robust studies with larger sample sizes and reliable outcome measures. Future research on the transition process should build on the strengths and limitations of current studies. Such work is vital because effective facilitation of NQN transition is key to helping new registrants to develop the essential knowledge, skills, confidence, competence and understanding for delivering effective person-centred care.