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3 considerations when transitioning new graduate nurses to rural practice

Transitioning new graduate nurses (NGNs) from school to the clinical environment has been a longstanding challenge, particularly in rural health care organizations. Although leaders in academia and practice share the same goal of ensuring new nurses are prepared to meet the demands of the constantly evolving health care landscape, they often have different points of view on practice readiness. While much of the focus has been on preparing graduates, we must remember that practice leaders should also be ready.
"When I graduated, I sought an organization that would foster and support my desire to grow and learn in my profession,” says Jill Imhoff, a registered nurse at Upland Hills Health, a critical access hospital in Dodgeville, Wis. Imhoff is not alone. According to Gallup, Gen Z and Millennials, who make up nearly half of the full-time workforce in the US, expect to be coached in their workplace and are more likely to say development opportunities are significant in selecting a new job.8 So what can an organization do? Here are three key considerations when preparing for NGNs to enter practice. 

1. Check your expectations.

Research on the transition to practice experience shows that NGNs enter as novices or advanced beginners. Throughout their first 12 months, their skills develop rapidly.2 Starting in the honeymoon phase, NGNs are excited to come to work and focused on learning the role of the professional nurse. Following orientation with a one-on-one preceptor, NGNs continue fine-tuning their skills and working independently.
During this time, nurses hit what Dr. Marlene Kramer identifies as reality shock, when they experience disillusionment realizing that practice is much different than expected.5 At this point, if nurses are not well supported, organizations risk experiencing turnover. When adequately supported, many NGNs eventually settle into their role, recovering and entering resolution.5
Theories around this topic tell us that transitioning from academia into practice takes time, and NGNs will move through somewhat predictable stages. Through each step, their skills will continue to develop, and the type of support needed will change.2,3,5 "With the support of my colleagues, family, friends, and the IONRP program, I made it through one of the most challenging years of my life as I transitioned from a student nurse to an independent and confident ER nurse,” Imhoff says

2. Acknowledge practice readiness is about more than just clinical skills.

There are three key factors that influence practice readiness. First, the intrapersonal factors of the nurse include their ability to cope with stress, their confidence, their ability to persevere despite difficult circumstances, and their general outlook. Interpersonal factors are also critical. The relationships they develop at work, their ability to work as a member of the interdisciplinary team, and the presence or absence of relational influences such as bullying, incivility, and lateral violence impact the transition to practice.
Finally, organizational or environmental factors also influence practice readiness. Robustness of orientation, skills of the preceptor, presence of support throughout the first year in the form of a residency program, and mentoring will impact the NGN throughout their transition. Research suggests that what NGNs are taught in school is essential; however, many other skills are developed through experience and exposure.6 "The ever-changing face of health care demands resiliency and support for success, so having an employer who values and recognizes the need for programs to help their employees is essential,” Imhoff says.

3. Integrate enablers of a positive transition to practice at the organizational level. 

Research identifies enablers and barriers to achieving an optimal transition to practice, which fall into four distinct categories.
Preceptors must be competent in skills needed to teach the NGN, including  communication, relationship building, and the ability to provide emotional support. Preceptors must also be provided with an adequate workload so they have the time to provide one-on-one feedback.9 Preparing preceptors is best done by establishing a preceptor program so all preceptors provide a similar experience.4
Residency programs
Structured learning experiences that allow NGNs focused time to connect the knowledge gained in school with their work environment helps to address the gap in readiness for practice. The availability of mentorship in various forms improves the NGN's sense of belonging to the profession and organization.9 Not only do these structured programs need to focus on the ongoing development of clinical and professional skills, but research shows they must be balanced with social and emotional development and support. 6,9
Staffing models
Prioritizing a limited scope of practice for NGNs until complete mastery is achieved is one way to offer support. Allowing time to focus on basic skills and slowly build to more complex assignments will help the NGN have a more positive experience. Another strategy is implementing alternative staffing models that use experienced nurses differently, meaning not all nurses are equal and carry equal loads of patients. This provides NGNs with more manageable patients until they have the competence and time management skills to handle more complex situations.10 Ensuring an educator or highly skilled nurse is available to serve as a resource especially during nights and weekends is another tactic to alleviate the loss of experience and redistribute clinical expertise while establishing career pathways.4
While each of these strategies can be helpful, the impact of the work environment cannot be overstated. Ensuring a supportive and safe work environment free from bullying, incivility, and lateral violence is essential.6 Safe staffing, shared decision-making, and professional development support that begins on day one and continues throughout the career through mentoring is also necessary. Finally, developing and tracking outcomes to value of initiating these enablers of a positive transition to practice and sharing these outcomes far and wide will help establish return on investment, helping gain ongoing buy-in and funding from organizational leaders.4
Although practice readiness is multifaceted and complex, rural health care organizations can still find success. Upland Hills Health is a great example of how implementing a healthy mix of these strategies leaves new graduates satisfied and successful. "I was fortunate to find a home with Upland Hills Health. I absolutely believe that the staff I've learned from and worked with played a pivotal role in my success, and I'm truly grateful," Imhoff says.
New nurses continue to fill positions vacated by retiring nurses. While educational programs work to prepare nurses for practice, it is equally important for health care organizations to implement evidence-based strategies to support these new nurses as they transition from students to professionals. This can be done by ensuring realistic expectations are held by all stakeholders, supporting personal and professional development needs, and implementing strategies that have been proven to enable a positive transition to practice experience.

NRHA adapted the above piece from Iowa Online Nurse Residency Programa trusted NRHA partner, for publication within the Association’s Rural Health Voices blog.

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