Content uploaded by Michelle Freeling
Author content
All content in this area was uploaded by Michelle Freeling on Sep 03, 2017
Content may be subject to copyright.
Content uploaded by Michelle Freeling
Author content
All content in this area was uploaded by Michelle Freeling on Sep 02, 2017
Content may be subject to copyright.
Review
Exploring experienced nurses' attitudes, views and expectations of new
graduate nurses: A critical review☆
Michelle Freeling
a,
⁎, Steve Parker
b,1
a
5/123 Hawker Street, Ridleyton, Adelaide 5008, Australia
b
School of Nursing and Midwifery, Flinders University, GPO Box 2100, Adelaide 5001, Australia
summaryarticle info
Article history:
Accepted 19 November 2014
Keywords:
New graduate nurses
Registered nurses
Nurse attitudes
Communication barriers
Job satisfaction
Work environment
Objectives: This critical review evaluates the existing primary research literature to identify experienced
registered nurses' attitudes, views and expectations of graduate nurses which may create a barrier for optimal
graduate nurse performance.
Design/Data Sources: Relevant primarystudies were identifiedby searching online databases using a wide variety
of appropriate keyword combinations.Online databases including Cumulative Index to Nursing and AlliedHealth
Literature (CINAHL),Scopus, PsycINFO and GoogleScholar were comprehensively searched for relevantresearch.
The selected studies were subjected to a rigorous critical appraisal to evaluate the studies and to determine if the
findings were applicable to practice.
Review methods: A manual method of thematic analysis was conducted to highlight explicit and implicit themes
from the reviewed studies. Themes were grouped and continually reduced until only essential themes remain.
Themes and subthemes emerged which were then compared and contrasted to analyse results. The four major
themes identified include nursing skills, inadequate preparation during academic program, attitudes and ward
culture and concerns with confidence. Subthemes were identified within these categories.
Results: Findings indicate experienced registered nurses discussed themes including ‘nursing skills’,‘inadequate
preparation during academic program’,‘attitudes and ward culture’and ‘concerns with confidence’. Concerns
were raisedincluding the value of traditionaltraining versus tertiary education programs,coping with unprofes-
sional behaviour and inadequate preparation for practice.
Discussion and implications for practice: Further research is required to fully address management of the
theory–practice gap, as well as the attitudes of experienced registered nurses educated in traditional programs
versus those in tertiary education programs. Nurse managers should be aware of the possible occurrence of
unprofessional behaviour, and increased workplace training regarding lateral violence would assist in raising
awareness regarding negative and unacceptable behaviour.
© 2014 Elsevier Ltd. All rights reserved.
Introduction
The challenges accompanying new nursing graduates entering the
workforce are numerous and multifaceted. There is a plethora of research
which examines the graduate nurse journey and subsequent feelings
and attitudes towards work place integration (Pellico et al., 2009;
Wangensteen and Johansson, 2008; Halfer and Graf, 2006 and McKenna
and Green, 2004). However, little research exists regarding the view of
the experienced registered nurse. It is evident that experienced registered
nurses significantly contribute to the development of the graduate nurse,
and experienced registered nurses as preceptors are widely recognised
to play an essential role in graduate nurse development (Sayers and
DiGiacomo, 2011; Giallonardo and Wong, 2010 and Johnstone et al.,
2008).
Negative staff attitudes have been highlighted as one of the most
powerful barriers of graduate nurse support (Johnstone et al., 2008). It
has been noted that a negative approach from senior nurses towards
graduate nurses creates a barrier for optimal skill utilization by the
graduate (Bircumshaw, 1989). Nursing is a profession which has been
perceived both historically and contemporarily as ‘eating its young’
(Meissner, 1986; Stanley et al., 2007 and Wolff et al., 2010) and many
graduate nurses find it challenging to become accepted in the culture
of the unit (Baumberger-Henry, 2012). To enable graduates to fulfil
their potential, the attitudes, views and expectations of experienced
registered nurses and graduate nurses must be explored. Only then
can these attitudes and feelings be addressed and methods put in
place to facilitate healthy graduate nurse/experienced registered nurse
relationships. This may ultimately allow graduate nurses to utilize
Nurse Education Today 35 (2015) e42–e49
☆There are no known conflicts of interestassociated with thispublication andthere has
been no significant financial support which may have influenced its outcome.
⁎Corresponding authorat: BN, RN School of Nursing and Midwifery FlindersUniversity
GPO Box 2100 Adelaide 5001, Australia. Tel.: +61 423580677.
1
Tel.: +61 882013402, +61 433463157.
http://dx.doi.org/10.1016/j.nedt.2014.11.011
0260-6917/© 2014 Elsevier Ltd. All rights reserved.
Contents lists available at ScienceDirect
Nurse Education Today
journal homepage: www.elsevier.com/nedt
their full range of skills, practice confidently and comfortably and be-
come a valuable part of the healthcare team.
Aim
The aim of this paper is to explore primary research literature to
identify experienced registered nurses' attitudes, views and expecta-
tions of graduate nurses which may create a barrier for optimal gradu-
ate nurse performance.
Search methods and outcomes
This literature review was undertaken to systematically evaluate
existing knowledge to inform a defined area of clinical practice
(Schneider et al., 2007, p. 47). Online databases Ovid Medline, Cumula-
tive Index to Nursing and Allied Health Literature (CINAHL), Scopus and
PsycINFO were comprehensively searched for relevant research. Vari-
ous keywords and combinations were utilised for example: graduate
and experienced and nurse and attitudes, nurse or health personnel
attitudes and graduate students and attitudes, new graduate nurse
and nurse attitudes, nurse manager and perspective or attitude or
view, graduate nurse and attitude of health personnel, graduate and
nurse and perception, preparation for practice and perception and
nursing staff, practice readiness and graduate nurse, registered nurse
and new graduate and perspective. ‘Nursing’and ‘peer reviewed’were
selected as criterion for the search.
A total of 1512 studies were identified and after title screening
and applying inclusion/exclusion criteria (Table 1), 31 articles were
retrieved and read. No parameters were applied regarding the year
the study was undertaken,as all studies regardingthoughts and feelings
of experienced registered nurses were considered to potentially contain
relevant, applicable information. For the purpose of this review, experi-
enced nurses are defined as having three or more years of post-graduate
experience and have some involvement in the supervision of graduate
nurses. The graduate nurse is defined as having 2 or less years of post-
graduate experience.
The full-text screening method required the study to be from the
perspective of experienced registered nurses, and to focus on the atti-
tudes, views and expectations of graduate nurses. After rejecting 22
studies, the reference lists were screened and one more relevant study
was located. Ten studies were read in full and a decision was made to
include all ten articles in the review. A total of 35 studies were located
and after applying the exclusion criteria (Table 1), 10 studies were
considered relevant. Out of these 10 studies, eight were identified from
database searching and two from the reference lists of studies which
did not meet the inclusion criteria. The search process is demonstrated
in Fig. 1 and the results are summarized in Table 2.
Critical appraisal
The 10 selected studies were subjected to a rigorous critical appraisal
to evaluate the studies, scrutinize the reliability between the research
problems and approaches, and determine if the findings were applica-
ble to practice (Schneider et al., 2007, p. 24). A total of 33 questions
from The Critical Review Guidelines for qualitative and quantitative
studies (Schneider et al., 2007) were applied toenable research process-
es, strengths and weaknesses and significant aspects of each study to
be evaluated. Two of the studies incorporated mixed method designs
so both qualitative and quantitative Critical Review Guidelines were
utilised.
Findings reveal thatnone of the studiesmet all the criteria ofthe crit-
ical appraisal. However, strengths and weakness of the studies were
Scopus, Ovid Medline, CINAHL , PsycINFO
(Entire Date Range)
1512 Citation(s)
Title Screening
Inclusion/Exclusion
Criteria Applied
1481 Art icles Excluded
After Title/Abstract Screen
31 Articles Retrieved
Inclusion/Exclusion
Criteria Applied 1 Articles ident ified thr ough refer ence list screen ing
9 Articles Excluded
After Full Text Screen
10 Ar t i cles Incl uded
Fig. 1. PRISMA flow diagram demonstrating the search process.
Table 1
Inclusion and exclusion criteria.
Inclusion criteria Exclusion criteria
Published in English language Published in a language other than English
Related to graduate nurses (2 years or less experience) and experienced nurses (3 years or more experience) Related to student nurses
Related to the experiences and perceptions of experienced nurses Related to the experiences and perceptions of graduate nurses
Related to the attitudes of experienced nurses towards graduate nurses
Primary research article or thesis Literature other than primary research articles or thesis
e43M. Freeling, S. Parker / Nurse Education Today 35 (2015) e42–e49
highlighted as a result of the appraisal process. All 10 studies explored a
phenomenon focused on human experience within a natural setting rel-
evant to nursing and healthcare. Nine of the studies extensively
reviewed current literature prior to this study, with only one paper
(Bircumshaw, 1989) failing to provide sufficient background informa-
tion and references to previous research. However, Bircumshaw
(1989) addressed this by highlighting a lack of literature regarding
the attitudes of senior nurses solely towards graduates. All 10 studies
identified the context, participant group and location of the method to
be followed; however Bircumshaw (1989) failed to identify the number
of sites from which participants were recruited. Three studies (Lofmark
et al., 2006; Hartigan et al., 2010 and Clark and Holmes, 2007) were
undertaken across multiple settings, whilst three other studies
(Baumberger-Henry, 2012; Hegney et al., 2012 and Wolff et al., 2010)
included participants from a variety of clinical areas. These techniques
are forms of data triangulation which, by including data from multiple
settings, increases the rigour of these studies (Denzin 1989 cited in
Taylor et al., 2011).
All ten studies used appropriatedata collection techniques withfour
studies employing a survey approach, five studies using focus group
methodology and one a longitudinal study. Focus groups and interviews
encourage individuals to express varying views extensively, allowing
for unique cases and encouraging discussion (Taylor et al., 2011).
Clark and Holmes (2007) employed both focus groups and individual
interviews, thus strengthening therigour by using more than one meth-
od of data collection (Taylor et al., 2011). Three studies included large
sample sizes, n= 150 (Wolff et al., 2010), n=3000(Hegney et al.,
2012) and n= 136 (Lofmark et al., 2006) which may increase rigour.
Two of the studies (Lofmark et al., 2006 and Hickey, 2009)useda
mixed methods approach, collecting both qualitative and quantitative
data, allowing data to be deepened and enriched further.
Data analysis techniques were discussed by nine studies with only
Bircumshaw (1989) failing to outline how this was undertaken. Five
of the studies increased reliability and validity (Walker et al., 2013;
Wolff et al., 2010; Chernomas et al., 2010; Clark and Holmes, 2007 and
Hartigan et al., 2010) through transcript review and validation by an-
other expert researcher. Limitations of the study were acknowledged
and discussed by only three of the reviewed studies (Walker et al.,
2013; Hegney et al., 2012 and Lofmark et al., 2006) whilst only Hegney
et al. (2012) reported researcher bias.
Results
A manual method of thematic analysis was conducted to highlight
explicit and implicit themes from the reviewed studies. This facilitates
qualitative data analysis which ultimately pursues the organisation of
words and phrases in light of the research goals (Taylor et al., 2011). A
coloured coding method as described by Taylor et al. (2011) was
employed to identify words, ideas and nuances which appeared to
have links. These themes were grouped and continually reduced until
only essential themes remain (Taylor et al., 2011). Categories and
themes within these categories emerged which were then compared
and contrasted to analyse results. Themes were then grouped and con-
nections highlighted to address the appraisal objective. The four major
categories which emerged were ‘nursing skills’,‘inadequate preparation
during academic program’,‘attitudes and ward culture’and ‘concerns
with confidence’(see Table 3). Themes also emerged in some of these
categories.
Nursing skills
Six of the reviewed studies (Lofmark et al. (2006),Hickey (2009),
Hartigan et al. (2010),Clark and Holmes (2007),Chernomas et al.
(2010) and Bircumshaw (1989)) explored nursing skills as a major cat-
egory. Whilst a wide range of specific skills are mentioned in these stud-
ies, common skills were identified and organised into themes. Themes
include clinical decision making, organisation and time management,
delegation and management skills, patient assessment, communication
and basic and advanced skills.
The need for graduates with well-developed clinical skills was fre-
quently conveyed in the studies informing this category. Lofmark et al.
(2006) found 75% or more of experienced registered nurses surveyed
believed the new graduate nurses they had encountered had a good
or strongly developed ability to provide nursing care. Other skills were
also rated as good or strongly developed including ethical awareness,
communication, team work, preparing for action, working speed
and self-knowledge (Lofmark et al., 2006). In contrast, another study
discovered more than 50% of experienced registered nurses highlighted
psychomotor and assessment skills, critical thinking, time management,
communication and teamwork as areas of weakness (Hickey, 2009).
Clinical decision making
The participants from the study of Hartigan et al. (2010) reported
the need for graduate nurses to have more confidence in clinical deci-
sion making abilities. One participant reported a hesitancy to commit
to decisions, despite often correctly judging the situation (Hartigan
et al., 2010). In another study, nurse managers discussed critical think-
ing as the most difficult adjustment in the transition from student to
registered nurse (Chernomas et al., 2010). Conversely, Bircumshaw
(1989) found graduate nurses have ‘an analytical approach to problem
solving and have a greater knowledge base’(p. 70) when compared to
traditionally trained nurse graduates.
Organisation and time management
Organisational skills were highlighted as a significant challenge to
graduate nurses (Chernomas et al., 2010). Clark and Holmes (2007)
found experienced registered nurses believe graduate nurses should
be taught how imperative time management skills are, and that if
nurses were hospital trained more time management experience
would be received. Another study found that only 13% of experienced
registered nurses surveyed believed graduate nurses could set priorities
most of the time and 47% thought this occurred sometimes (Hickey,
2009). Further, experienced registered nurses thought 35% of graduate
nurses demonstrated appropriate time management skills sometimes;
whilst 80% felt graduate nurses demonstrated organisational skills
sometimes or less often (Hickey, 2009).
Delegation and management skills
According to Hickey (2009), delegation skills were demonstrated
sometimes or less often according to 80% of experienced registered
nurse respondents. This was confirmed by another study in which
nurse managers highlighted the need for new nurses to have compe-
tent team leadership and supervision skills (Chernomas et al., 2010).
Delegation skills were also highlighted as a graduate nurse weakness
(Chernomas et al., 2010). Bircumshaws' findings also inform this
theme stating many graduate nurses lack practical experience in nursing
patients and need to learn ward management and staff management
skills (1989).
Patient assessment
Patient assessment and the ability to recognise change and deterio-
ration were emphasizedby respondents to be vital to patient outcomes
(Hartigan et al., 2010). Participants gave numerous accounts to illus-
trate outcomes which occurred when graduate nurses did not have
the skills to recognize deterioration (Hartigan et al., 2010). Further,
only 50% of responding experienced registered nurses found physical
assessment by graduate nurses to be sometimes adequate (Hickey,
2009).
e44 M. Freeling, S. Parker / Nurse Education Today 35 (2015) e42–e49
Table 2
Summary of reviewed articles.
Author
Year
Country
Study Aim/objectives Sample and characteristics Method Major Findings
Lofmark et al.
(2006))
Swedish
Competence of
newly-graduated nurses—a
comparison of the
perceptions of qualified
nurses and students
Compares opinions of final
year nursing students, rating
their own competence, with
the opinions of experienced
nurses on the competence of
newly graduated nurses.
106 nursing students from two
universities and 136
experienced nurses from two
hospitals
Questionnaire with 18
items
Nursing students rated their own competence as good or strongly developed in most
investigated areas
Experienced nurses estimated new grads' competence to be good or strongly developed,
although to a lesser extent
Nurses qualified within the previous 5 years rated new grad nurses' competence higher in
comparison to those with less recent education
Hickey (2009)
American
Preceptor perceptions of
new graduate nurse
readiness for practice
To identify preceptors' views of
new graduates' readiness for
practice using a specificsetof
criteria
62 preceptors Questionnaire with 18
items (rating scale and
open-ended)
Mixed method research
Mean scores higher on each of the importance scales, indicating that preceptors viewed the
items as more important than what was actually observed
More than 50% of responses indicated that the clinical experiences during the academic
program do not adequately prepare the graduate for practice
Hartigan et al.
(2010)
Ireland
Acute nursing episodes
which challenge graduate's
competence: perceptions
of registered nurses
To identify challenging acute
nursing episodes which
experienced nurses perceive
as difficult for new grads
To identify key aspects of
competence which new grads
need to deal with acute episodes
28 nurses with preceptor
experience
Qualitative descriptive
design
Focus group discussions
41 challenging acute nursing episodes were identified and four aspects of competence are
required to manage these
This research suggests experienced nurses believe new grads lack a number of the key
competencies required to manage acute episodes
Experienced nurses believe some of the acute nursing episodes were unexpected due to their
simplistic nature and frequency of occurrence in clinical practice
Technical/clinical skills are not often performed to the standard experienced nurse expect
UK
Clark and
Holmes
(2007)
Fit for practice? An
exploration of the
development of newly
qualified nurses using
focus groups
Aims to gain an understanding
of the way that competence
develops amongst nurses
themselves and how this is
seen by their managers and
those working with them
105 staff formed focus groups
and 5 ward managers
interviewed individually
Focus groups and
individual interviews
Clearly suggests it cannot be assumed that new nurses are competent to practice
independently and without supervision at the time of registration
Senior staff sometimes have negative attitudes towards new grads' abilities to perform and
some staff have greater expectations
There is a lack of confidence on behalf of the new nurse and also a reluctance to permit
autonomy on behalf of the experienced nurse whose views may be clouded by previous
experience
Support offered by preceptors was seen as crucial to the development of competent practice
Recognises a relationship between the support offered by the preceptor and the learning that
was achieved
Australia
Hegney
et al. (2012)
Queensland nursing staffs'
perceptions of the
preparation for practice of
registered and enrolled
nurses
Address the gap in the
knowledge if how clinical
nurses perceive the ‘work
readiness’of new nurses
Approximately 70% of 3000
people provided comments on
the question ‘please list for us
5 key issues and strategies that
you could see improve nursing
and nursing work’
Survey with 70
questions
Experienced nurses perceive a lack of clinical exposure and inappropriate curriculum content
Experienced nurses believe there should be changes to the entry practice preparation for
nurses
The attitude of clinical nurses influence the workplace experience of student nurses
Walker et al.
(2013)
Australia
Graduate nurses' transition
and integration into the
workplace: a qualitative
comparison of graduate
nurses' and nurse unit
managers' perspectives
To compare grad nurses' and
nurse unit managers'
perceptions regarding the
workplace factors that affect
graduate nurses' transition
and integration into the
workplace
69 graduate nurses and 25
nurse unit mangers
Group and individual
interviews
Results indicate a need for nurse unit managers to be alert to the possible occurrence of
unprofessional workplace behaviour on the ward and its negative impacts particularly for new grads
Nurseunitmanagersdidnotseeshiftworkasanissuespecifically for new grads but one that
impacts all nurses. This attitude may impair nurse unit managers' sensitivity to the difficulty of
transitioning to shift work and to grad nurses' possible need for support with this process.
Recognised that support provided in the current workplace impacted grad nurses’confidence and
facilitated successful integration into the workplace
(continued on next page)
e45M. Freeling, S. Parker / Nurse Education Today 35 (2015) e42–e49
Table 2 (continued)
Author
Year
Country
Study Aim/objectives Sample and characteristics Method Major Findings
Wolff et al.
(2010)
Canada
New graduate nurse
practice readiness:
perspectives on the context
shaping our understanding
and expectations
To understand the
perspectives of nurses about
new graduate nurse readiness
and the underlying context
shaping these perspectives
150 nurses Focus groups Perception that diploma prepared nurses were better equipped than baccalaureate-prepared
nurses to ‘walk into’practice settings and perform competently.
Participants suggested that nurses educated in baccalaureate programs were encouraged to
question orders and practices in a way that would have been unacceptable in a more
traditional or college-based diploma program.
Some nurses questioned the commitment of new grads to the workplace environment. New
grads were perceived as less likely to be committed to organizations or particular nursing
units, choosing instead to embrace work/life balance. This perceived lack of commitment
caused some of the nurses to express a hesitancy to embrace new grads.
USA
Baumberge-
r-Henry
(2012)
Registered nurses'
perspectives on the new
graduate working in the
emergency department or
critical care init
Despite all that is known about
the new graduate nurse, little
has been discussed regarding
the perceptions of the
registered nurse who works
with this advanced beginner.
This study was conducted to
gain an understanding of the
experienced nurse's
perception of the newly
graduated nurse who is
working in an emergency or
critical care area.
31 experienced nurses Focus groups Registered nurses were disillusioned by the lack of confidence, organization, and skill
performance of the new graduate. They agreed that nurses “eat their young.”
Canada
Chernomas
et al. (2010)
“Hit the ground running”:
perspectives of new nurses
and nurse managers on
role transition and
integration of new
graduates
As part of a larger study that
examined the effectiveness of
a new strategy on new nurse
retention and workplace
integration, we conducted
focus groups with new nurses
and nurse managers. This
paper discusses the
perspectives of new nurses on
their role transition from
graduates to practising
professionals and the
perspectives of nurse
managers on the workplace
integration of new nurses.
Separate focus groups of nurse
managers and new graduates.
(Three focus groups were held
in which nurse managers were
asked about the major issues
they face in integrating and
retaining new graduates, their
perceptions of the challenges
that new nurses face in
integrating into the workplace
and strategies they use to
integrate and retain new
nurses.)
Focus groups Content was compared and contrasted.
Three themes were identified that characterized the experiences of transition for new nurses
participating in the project: “Know who I am,”“Know what I need”and “I feel prepared, but…”
The analysis of nurse managers' focus group discussions indicated data clustered around the
same themes; therefore, nurse managers' perspectives were incorporated into the themes for
the new nurses.
Bircumshaw
(1989)
UK
A survey of the attitudes of
senior nurses towards
graduate nurses
To obtain the views of senior
nurses in the areas where
graduates included in the main
study were working.
Descriptive survey approach.
18 DON/chief nurses
Survey Findings demonstrate varied views on whether graduates should and do function differently to
traditionally trained nurses.
Majority of subjects felt that graduates function differently from traditionally trained nurses
Findings suggest that if graduate's skills are not recognised by those in senior posts, they may
not be utilised to their full potential, as specific views of senior nurses are likely to influence
the posts held by graduates.
e46 M. Freeling, S. Parker / Nurse Education Today 35 (2015) e42–e49
Communication
Communication and interaction were extensively reported in one of
the reviewed studies. Comments by respondents conveyed frequent
failure by graduate nurses to communicate abnormalities in patient
observations to the necessary persons (Hartigan et al., 2010). One re-
spondent stated ‘it's like one of those things you have to go through to
learn’(Hartigan et al., 2010, p. 294). Generally, respondents recognized
the difficulty of graduate nurse role transition.
Basic skills
Graduate nurses received positive reports regarding basic nursing
skills in the study that informs this theme. Seventy-two percent of
preceptors reportedthat graduate nurses are able to perform basic tech-
nical skills most of the time (Hickey, 2009).
Advanced skills
Clinical skills such as administering pain relief, managing falls, calcu-
lating urinary output and titrating insulin were named as challenging
for graduate nurses (Hartigan et al., 2010). Experienced registered
nurses reported graduate nurses did not often accomplish clinical skills
to the standard they expect (Hartigan et al., 2010). Participants also
discussed graduate nurse reliance on machinery to determine vital
observations (Hartigan et al., 2010). This was confirmed by Hickey,
who found 76% experienced registered nurses believe graduate nurses
could independently and competently perform advanced technical
skills sometimes or less often (Hickey, 2009).
Inadequate preparation during academic program
Six studies identified a perceived lack of clinical experience and lack
of appropriate content during academic programs. Participants in
one study felt material required to competently work in a specialised
area such as emergency or critical care is often not taught as part of
undergraduate education (Baumberger-Henry, 2012). One study dem-
onstrated experienced registered nurses reported only 11% of graduate
nurses were more competent than those who had graduated under the
old curriculum, whilst 41.3% perceived graduate nurses as less compe-
tent (Lofmark et al., 2006). More than 50% of experienced registered
nurse respondents in another study reported clinical experiences
throughout the academic program result in inadequate preparation
for practice(Hickey, 2009). Onerespondent stated ‘themain thing grad-
uates seem to be lacking in is the reality of how much is required to do
the job’(Hickey, 2009, p. 39).
The study of Hegney et al., 2012 found many experienced registered
nurses believed an increase in the amount of clinical work during the ac-
ademic program would better prepare students for practice (Hegney
et al., 2012). Respondents conveyed their beliefs that this would better
prepare the nurse for the challenges of nursing, whilst some believed
nurse preparation should return fully to hospitals (Hegney et al.,
2012). One respondent stated ‘this would improve nurses' hands-on
skills and nurses would study in the industry as this would sort out
real nurses from over-educated people who are not really interested
in hands-on nursing’(Hegney et al., 2012, p. 1150). Generally partici-
pants felt that curriculum could better prepare students for nursing
and their understanding of the requirements of a nursing career includ-
ing the demands of shift work and passion for the nursing profession
(Hegney et al., 2012). This was confirmed by another study which
found experienced registered nurses felt graduates take longer to settle
into their first staff nurse post, equivalent to that of a first year registered
nurse in Australia, due to lack of clinical experience (when compared
with traditionally trained nurses) (Bircumshaw, 1989).
Another study found participants felt the mode of nursing education
influenced the socialisation of graduate nurses which in turn influenced
readiness to practice (Wolff et al., 2010). Experienced registered nurses
felt questioning orders and practices were encouraged and this would
have been unacceptable in traditional programs (Wolff et al., 2010).
Further, respondents also felt traditionally trained nurses were better
equipped to begin work and perform competently; lack of clinical
practice hours and the varied nature of clinical learning were thought
to contribute (Wolff et al., 2010).
Attitudes and ward culture: negative attitudes/criticism
Four studies identified negative attitudes and criticism as a significant
aspect of experienced registered nurse behaviour towards graduate
nurses. An alleged absence of commitment to nursing and particular
wards caused some experienced registered nurses to express hesitancy
towards graduate nurses (Wolff et al., 2010). Many believed graduate
nurses choose to embrace work/life balance and fail to demonstrate the
levelofcommitmentofotherstaffmembers(Wolff et al., 2010). One re-
spondent stated ‘if they're not invested in the idea of working on that
Table 3
Categories and themes identified from reviewed studies.
Categories Themes No. of
studies per
theme
Empirical sources
Nursing skills 6 Lofmark et al. (2006),Hickey (2009),Hartigan et al. (2010),Clark and Holmes (2007),
Chernomas et al. (2010),Bircumshaw (1989)
Preparing for action/clinical decision
making/critical thinking
4Lofmark et al. (2006),Hartigan et al. (2010),Chernomas et al. (2010),Bircumshaw (1989)
Working speed/time
management/organization
4Lofmark et al. (2006),Hickey (2009),Clark and Holmes (2007),Chernomas et al. (2010)
Delegation/management skills 3 Hickey (2009),Chernomas et al. (2010),Bircumshaw (1989)
Patient Assessment 2 Hickey (2009),Hartigan et al. (2010)
Communication with patients 2 Lofmark et al. (2006),Hartigan et al. (2010)
Basic skills Hickey (2009),Bircumshaw (1989)
Advanced Skills 1 Hickey (2009)
Inadequate preparation during
academic program
6Lofmark et al. (2006),Hickey (2009),Hegney et al. (2012),Wolff et al. (2010),
Baumberger-Henry (2012),Bircumshaw (1989)
Lack of clinical experience 3 Hickey (2009),Hegney et al. (2012),Wolff et al. (2010),
Attitudes and ward culture 6 Clark and Holmes (2007),Walker et al. (2013),Wolff et al. (2010),Baumberger-Henry
(2012),Chernomas et al. (2010) ,Bircumshaw (1989)
Negative attitudes/criticism 4 Clark and Holmes (2007),Walker et al. (2013),Wolff et al. (2010),Baumberger -Henry
(2012),
Unprofessional behaviour 2 Walker et al. (2013),Baumberger-Henry (2012),
Concerns with confidence 3 Clark and Holmes (2007),Baumberger-Henry (2012),Chernomas et al. (2010),
e47M. Freeling, S. Parker / Nurse Education Today 35 (2015) e42–e49
floor, then maybe some of the old guard is not that invested in working
with them, either’(Wolff et al., 2010, p. 189). Work ethic was also
highlighted, with calling in sick and work expectations representative
of the generational differences between experienced registered nurses
and graduate nurses (Chernomas et al., 2010). Another respondent
highlighted a generational difference, believing graduate nurses wanted
to learn and move on thus demonstrating a lack of loyalty (Chernomas
et al., 2010).
One study highlighted the varying types of ward culture, with one
experienced registered nurse stating ‘each centre has its own culture
and if you've done most of your training at one, and then you're going
to another one (upon hiring), that's another big change. Who you talk
to, and how you talk to them, is very different’(Chernomas et al.,
2010, p. 76). Another study found one focus group discussed the
concern with graduate nurses failing to accept feedback, namely when
it was negative (Chernomas et al., 2010). One participant stated ‘it's a
different generation. And as positively as you try to make it, they take
it probably much harsher, I believe, than the generation before’
(Chernomas et al., 2010,p.77).
Unprofessional behaviour
In Walker et al.'s study a small number of nurse unit managers identi-
fied the occurrence of unprofessional behaviour such as belittling and
negative criticism; the link between these behaviours and demoralisation
and promotion of poor self-esteem was also discussed (2013). These be-
haviours have been highlighted as one of the most recurrently experi-
enced stressors during the graduate nurse year and negatively impact
on successful workplace integration (Walker et al., 2013). Desensitisation
and acceptance of this culture were suggested as one reason nurse unit
managers may not be aware of this type of behaviour (Walker et al.,
2013). This was confirmed by Bircumshaw who found that specific
views of particular senior nurses are likely to impact the posts held
by graduates and the degree to which they are able to utilize their
knowledge and skills (1989). A respondent from this study commented
that one significant issue is that educators, managers and ward staff
accept the change of educational mode to university-based training
(Bircumshaw, 1989).
Another study described the uncooperative behaviours that many
nurses exhibit and the graduate nurse's struggle to work around these
encounters and difficult personalities (Baumberger-Henry, 2012). One
respondent demonstrated this by stating ‘some nurses turn their backs
when the new grad asks a question or asks for help’; these behaviours
prevent graduate nurses gaining acceptance in the unit culture
(Baumberger-Henry, 2012, p. 302). This study also highlighted challeng-
ing personalities as the reason some graduate nurses do not succeed,
with another participant stating ‘one nurse on the unit has “killed”so
many nurses. She would sit at the desk and look at the new grads and
say that some of them won't make it, that they shouldn't be nurses, or
that they are stupid’(Baumberger-Henry, 2012,p.302).
Concerns with confidence
Lack of confidence and fear inhibiting practice was an issue
expressed by experienced registered nurses in three studies. One
study found experienced registered nurses felt graduate nurses lacked
appropriate time management skills and thought fear was a factor
inhibiting optimal practice (Baumberger-Henry, 2012). Fear was
expressed in another study, with one respondent stating ‘some fear is
good, but you need to use that to move forward’and ‘I think their
biggest fear coming in is that they're frightened they're going to make
a mistake’(Chermonas et al., 2010,p.80).
Another study explored confidence of issues relating to conformity
to tradition and established expectations ofthe staff nurse role. A reluc-
tance to permit autonomy on behalf of the experienced nurse was
verbalised and many felt this was due to previous negative experiences
with graduate nurses (Clark and Holmes, 2007). Further, graduate nurse
overconfidence was also perceived by some experienced registered
nurses with one ward manager stating ‘people are quite arrogant and
they forget that they were there and that's why they need the support
and I think if anybody ever thought they were ready to practice, they
weren't’(Clark and Holmes, 2007, p. 1215).
Limitations
Results demonstrate a lack of studies regarding the views, attitudes
and expectations of experienced registered nurses towards graduate
nurses. The small number of studies which exist on this subject may
affect the ability to apply the findings from this review. The majority
of the reviewed studies were qualitative and used only focus groups
and surveys as methods to gather data.
Discussion and implications for practice
Evidently, experienced registered nursed feel graduate nurses
are significantly lacking in the essential clinical skills required to suc-
cessfully transition from student to graduate nurse. There is a disparity
between nursing as taught and nursing as practiced which can be
described as the theory–practice gap (Gallagher, 2004). There are a
number of professional and organisational factors whichprevent imple-
mentation of nursing values adopted during undergraduate nursing
courses (Maben et al., 2006). Factors which prevent the translation of
theory into practice include obeying covert rules, lack of support, poor
nursing role models, time pressures, role constraints, work overload
and staff shortages (Maben et al., 2006). Further research is required
to fully address management of this theory–practice gap.
Graduate nurse programs, also known as transition to professional
practice programs, have been demonstrated to close the theory–practice
gap and develop graduate nurse skills and knowledge through supported
workplace learning (Casey et al., 2004). However, what constitutes best
practice for offering graduate nurses support must be considered. Cubit &
Ryan found debriefing and bonding, the orientation process and being a
supernumerary staff member, the induction process, preceptorship and
assessment and feedback to be key elements of an effective graduate
nurse program (2011). Graduate nurse programs must be constantly
evaluated to ensure they are meeting the needs of new nursing genera-
tions and providing the support required to successfully transition from
student to nurse.
This review identified the belief that graduate nurses are inadequately
prepared for practice during academic programs. Factors including insuf-
ficient access to satisfactory clinical placements and a predicted nursing
shortage place significant emphasis on the preparedness of student
nurses to practice competently as new graduates (Haddad et al., 2013).
Before the tertiary sector was responsible for registered nurse education,
student nurses were recruited directly by a hospital where they lived and
trained through an apprenticeship model (Mannix et al., 2009). This re-
view highlighted the continuing debate regarding traditionally training
versus university trained nurses, with Lofmark et al. reporting the percep-
tion that only 11% of graduate nurses were more competent than those
who had graduated under the old curriculum, whilst 41.3% perceived
graduate nurses as less competent (2006). However, many do not consid-
er the limitations associated with this traditional training method.
Greenwood (2000) stated that ‘the apprenticeship model also failed to
equip nurses with the skills required to respond to changing health-care
needs’(p. 18). It would be valuable for research to be undertaken regard-
ing the attitudes of experienced registered nurses educated in traditional
programs versus those in tertiary education programs and their percep-
tions of new graduates.
Unprofessional behaviour formed a significant theme of this review.
New graduate nurses often experience negative behaviours such as nega-
tive criticism, belittling and bullying (Randle, 2003; Boychuk-Duchscher
and Cowin, 2004; Walker et al., 2013). Kivimaki et al. (2000) refer to
e48 M. Freeling, S. Parker / Nurse Education Today 35 (2015) e42–e49
workplace bullying as ‘a situation where someone is subjected to social
isolation or exclusion, his or her work and efforts are devalued, he or
she is threatened, derogatory comments about him or her are said behind
his or her back, or other negative behaviour aimed to torment, wear
down, or frustrate occur’(p. 656). Nurse-to-nurse ‘social devaluation or
controlofapeerthroughovertandcovert verbal, physical and emotional
abuse’is known as lateral/horizontal violence and is a significant source of
work-related stress (Embree & White 2010 cited in Ceravold et al., 2012,
p. 599). Smith et al. demonstrated that lateral violence is experienced
by up to 90% of nurses (2010). This type of unprofessional behaviour
can significantly impact nurses and can lead to stress, physical, mental
and emotion illness, increased sick leave and increased staff turnover
(Kivimaki et al., 2000).
Lateral violence is often normalised by nursing teams because of
previous exposure to bullying from a supervisor (Hutchinson et al.,
2010) and acceptance of this behaviour from nurses who demonstrate
clinical superiority (Lindy and Schaefer, 2010). Desensitisation and
acceptance of this culture is one reason nurse unit managers may not
be aware of this type of behaviour (Walker et al., 2013). Increased
acceptance of the change from traditionally trained to university trained
nurses may decrease negative behaviours (Bircumshaw, 1989). Whilst
there is a large body of research investigating the negative physical
and emotional effects of bullying, further research needs to be under-
taken to ascertain the feelings experienced by nurseswhich first prompt
lateral violence. Further, Ceravolo et al. demonstrated the value of
implementing communication workshops to overcome lateral violence
(2012). Sixty- to 90-minute workshops intending to improve assertive
communication abilities were implemented after which nurses felt
more confident and determined to solve occurrences of lateral violence
(Ceravold et al., 2012). Perhaps increased workplace training regarding
lateral violence would assist in raising awareness regarding negative
and unacceptable behaviour and would provide necessary coping
mechanisms.
References
Baumberger-He nry, M., 2012. ‘Registered nurses ’perspectives on the new graduate
working in the emergency department or critical care unit. J. Contin. Educ. Nurs. 43
(7), 299–305.
Bircumshaw, D., 1989. A survey of the attitudes of senior nursestowards graduate nurses.
J. Adv. Nurs. 14 (1), 68–72.
Boychuk-Duchscher, J.E., Cowin, L., 2004. Multigenerational nurses in the workplace. J.
Nurs. Adm. 34 (11), 493.
Casey, K., Fink, R., Krugman, M., Propst, J., 2004. The Graduate Nurse Experience. J. Nurs.
Adm 34 (6), 303–311.
Ceravold, D.J., Schwartz, D.G., Folts-Ramos, K.M., Castner, J., 2012. Strengthening commu-
nication to overcome lateral violence. J. Nurs. Manag. 20, 599–606.
Chernomas, Care W.D., McKenzie, J.L., Guse, L., Currie, J., 2010. Hit the ground running:
perspectives of new nurses and nurse managers on role transition and integration
of new graduates. Nurs. Leadersh. 22 (4), 70–87.
Clark, T., Holmes, S., 2007. Fit for practice? An exploration of the development of newly
qualified nurses using focus groups. Int. J. Nurs. Stud. 44, 1210–1220.
Gallagher, P., 2004. How the metaphor of a ga p between theory and practice has
influenced nursing education. Nurse Educ. Today 24 (4), 263–268.
Giallonardo, L.M., Wong, C.A., 2010. Authentic leadership of preceptors: predictor of new
graduate nurses' work engagement and job satisfaction. J. Nurs. Ma nag. 18 (8),
993–1003.
Greenwood, J., 2000. Critique of the graduate nurse: an international perspective. Nurse
Educ. Today 20 (1), 17–23.
Haddad, M.E., Moxham, L., Broadbe nt, M., 2013. Gradu ate registered nurse practice
readiness in the Au stralian conte xt: an issue worth y of discussion. University of
Wollongong Research Online, Faculty of Science, Medicine and Health.
Halfer, D., Graf, E., 2006. Graduate nurse perceptions of the work experience. Nurs. Econ.
24 (3), 150–157.
Hartigan, I., Mur phy, S., Flynn, A.V., Walshe, N., 2010. Acute nursi ng episodes which
challenge graduate's compete nce: Perceptions of register ed nurses. Nurs e Educ.
Pract. 10, 291–297.
Hegney, D., Eley, R., Francis, K., 2012. Queensland nursing staffs' perceptions of th e
preparation for practice of registered and enrolled nurses. Nurse Educ. To day 33
(10), 1148–1152.
Hickey, M.T., 2009. Preceptor perceptionsof new graduate readinessfor practice. J. Nurses
Staff Dev. 25 (1), 35–41.
Hutchinson, M., Wilkes, L., Jackson, D., Vickers, M.H., 2010. Integrating individual, work
group and organizational factors: testing a multidimensional model of bullying in
the nursing workplace. J. Nurs. Manag. 18 (2), 173–181.
Johnstone, M.J., Kanitsake, O., Currie, T., 2008. The nature and implications of support in
graduate nurse transition programs: an Australian study. J. Prof. Nurs. 28 (1), 46–53.
Kivimaki, M., Elovainio, M., Vahtera, J., 2000. Workplace bullying and sickness absence in
hospital staff. Occup. Environ. Med. 10 (57), 656.
Lindy, C., Schaefer, F.,2010. Negative workplace behaviours: an ethical dilemma for nurse
managers. J. Nurs. Manag. 18, 285–292.
Lofmark, A., Smide, B., Wikblad, K., 200 6. Competence of newly-graduated nurse s—a
comparison of the perceptions of qualified nurses and students. J. Adv. Nurs. 53 (6),
721–728.
Maben, J., Latter , S., Macleod Clark , J., 2006. The theory–practice gap: impact of
professional–bureaucratic work conflict on newly‐qualified nurses. J. Adv. Nurs. 55
(4), 465–477.
Mannix, J., Wilkes, L., Luck, L., 2009. Key stakeholders in clinical learning and teaching in
Bachelor of Nursing programs: A discussion paper. In: (Advances in Contemporary
Nurse Education.) Contemp. Nurse 32 (1-2), 59–68.
McKenna, L.G., Green, C., 2004. Experiences and learning during a graduate nurse
program: an examination using a focus group approach. Nurse Educ. Pract. 4 (4),
258–263.
Meissner, J.E., 1986. Nurses: are we eating our young? Nursing 16 (3), 51–53.
Pellico, L.H., Brewer, C.S., Kovner, C.T., 2009. What newly licensed registered nurses have
to say about their first experiences. Nurs. Outlook 7 (4), 194–203.
Randle, J., 2003. Bullying in the nursing profession. J. Adv. Nurs. 43 (4), 395–401.
Sayers, J.M., DiGiacomo, M., 2011. The nurse educator role in the acute care setting in
Australia: important but poorly described. Aust. J. Adv. Nurs. 28 (4), 44–83.
Schneider, Z., Whitehead,D., Elliot, D., 2007. Nursing & midwifery research: methods and
appraisal for evidence-based practice. 3rd ed. Mosby Elsevier, Sydney.
Stanley, K.M., Dulaney, P., Martin, M.M., 2007. Nurses' eating our young—it has a name:
lateral violence. S. C. Nurs. 14 (1), 17–18.
Taylor, B., Kermode, S., Roberts, K. (Eds.), 2011. Research in nursing and health care:
evidence for practice, 4th edn CENGAGE Learning, South Melbourne.
Walker, A., Earl, C., Costa, B., Cuddihy, L., 2013. Graduate nurses' transition and integration
into the workplace: a qualitative compariso n of graduate nurses' an d nurse unit
managers' p erspectives. Nurse Edu c. Today 33, 291 –296.
Wangensteen, D., Johansson, I.S., 2008. ‘The first year as a graduate nurse—an experience
of growth and development. J. Clin. Nurs. 17 (14), 1877–1885.
Wolff, A.C., Pesut, A., Regan, S., 2010. Newgraduate nurse practice readiness: perspectives
on the context shaping our understanding and expectations. Nurse Educ. Today 30,
187–191.
e49M. Freeling, S. Parker / Nurse Education Today 35 (2015) e42–e49
