TRANSITIONING FROM NOVICE TO COMPETENT:WHAT CAN WE LEARN FROM THE LITERATURE

ABOUT GRADUATE NURSES IN THE

EMERGENCY SETTING?

Author: Anna Maria Valdez, RN, PhD, CEN, Salida, Calif

Earn Up to 10 CE Hours. See page 495.

Several significant issues and trends in nursing are im-portant to consider when projecting the future ofemergency nursing education. The first and arguably

most significant issue is the shortage of registered nurses,which is predicted to steadily increase during the next de-cade.1 The trend of experienced nurses leaving the patient’sbedside due to retirement, work environment dissatisfac-tion, or both, has contributed to a significant shortage ofskilled nurses available to fill acute care vacancies. To ad-dress this growing shortage of America’s nurses—whilemeeting the changing needs of an increasingly complexpopulation of patients—health care organizations are mak-ing every effort to recruit and retain talented nurses.

With the pool of candidates being limited and nursingvacancies approaching 9% across the United States, hospi-tals are turning to schools of nursing to produce compe-tent graduate nurses (GNs) to meet current and projectedhealth care demands.1 In an effort to address the crisis levelstaffing challenges experienced on a daily basis in U.S. acutecare hospitals, these neophyte nurses are being recruitedfor and hired to practice in highly specialized patient careunits, including the emergency department. In spite of re-search documenting the plethora of stressors faced by nov-ice and advanced beginner nurses while assimilating intothe clinical environment, no standardization of the GNorientation process has occurred.2-7

Newly graduated nurses often experience a cultureshock when transitioning from the academic ideal of nurs-

ing to the clinical reality of nursing practice. Rapid immer-sion into the modern-day acute care work environmentand feelings of inadequacy lead many new graduates to feeloverwhelmed, unsupported, and disillusioned.4 Knownstressors that accompany entry into practice, coupled withthe high-stress, fast-paced, life-and-death environment ofthe emergency setting, place the new graduate at increasedrisk for failure to thrive in clinical practice.

A number of resources are available that identify coreknowledge for nurses developing competence in the emer-gency setting.8,9 ENA has invested significant resourcesto develop competency-based educational programs (ie,Emergency Nursing Orientation Course, Trauma NurseCore Curriculum (TNCC), and ENPC) for nurses practic-ing in the emergency setting. These resources are criticalelements of the postregistration education for ED nurses;however, they are designed to be utilized as a part of anindividualized, clinically based, blended learning program.Rather than recapitulating what expert emergency nursesalready have identified as core and developmental compe-tencies for ED nurses, this article will summarize what isknown about the GN experience and provide recommen-dations for nurse educators that are charged with designingan educational plan to facilitate the transition from noviceto competent in the emergency department.

Theoretical Foundation: Novice to Expert Practice

According to Benner,10 the transition from novice to expertoccurs as a result of experiential learning in the clinicalpractice setting. In her seminal publication, From Noviceto Expert: Excellence and Power in Clinical Nursing Practice,Benner describes a body of practical knowledge embeddedin nursing practice.10 Utilizing the Dreyfus Model of SkillAcquisition applied to the nursing profession, Benner de-scribes the process of clinical judgment and skill develop-ment at 5 levels of proficiency: novice, advanced beginner,competent, proficient, and expert.

Anna Maria Valdez, Sacramento Chapter, is director of clinical services,REACH Air Medical Services, Santa Rosa, Calif.

For correspondence, write: Anna Maria Valdez, RN, PhD, CEN, 451 Avia-tion Blvd, Santa Rosa, CA 95403; E-mail: anna_valdez@mediplane.com.

J Emerg Nurs 2008;34:435-40.

Available online 15 May 2008.

0099-1767/$34.00

Copyright © 2008 by the Emergency Nurses Association.

doi: 10.1016/j.jen.2007.07.008

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October 2008 34:5 JOURNAL OF EMERGENCY NURSING 435

NOVICE

Novices in nursing are beginners with no prior experience inthe nursing practice they are expected to perform. Duringthis phase of skill acquisition, the learner has negligible con-textual understanding of the theories and concepts theyare being taught. To guide clinical practice and patient careexperiences, the novice learns measurable nursing “rules”and procedures. A lack of situational context with whichto correlate rule application limits the novice nurse and gen-erally results in an inflexible, universal approach to clinicalpractice. This level of proficiency is frequently seen in theprelicensure nursing student, although even an experiencednurse entering a new specialty role may function at thisproficiency level.10 New graduate nurses enter the acute caresetting with some contextual understanding of the rulesand procedures of clinical nursing; however, often thesenurses have not had sufficient exposure to the emergencysetting to practice beyond the novice level.

ADVANCED BEGINNER

The advanced beginner has been exposed to patient situa-tions of sufficient variety and complexity to progress to amarginally acceptable level of performance. Patient situa-tions may have been direct patient care or exposure throughmentoring in the clinical setting. The rules and proceduresof nursing practice are no longer context free for the ad-vanced beginner. At this stage of experiential learning,the nurse is beginning to see the whole clinical pictureand is able, with assistance, to recognize unique aspects orcharacteristics of individual patient situations.10 Nurses atthis level of skill acquisition frequently are asked to func-tion independently—often without a sense of comfort orconfidence—in the acute care setting. During this phaseof the experiential learning process, nurses need supportand mentoring by experienced nurses who have reachedat least the competent level of skill and performance.10

COMPETENT

Competent nurses have a broader perspective; they are ableto see nursing actions in terms of long-range patient caregoals. During this phase of skill acquisition, the nurse planscare based on identified priorities rather than providingstimulus-response–based interventions. According to Benner,10

the competent nurse lacks the speed and flexibility of theproficient nurse; however, at this level of aptitude, the nurseis able to cope with and manage many of the more chal-lenging contingencies of clinical nursing practice. Althoughthere is no established time frame that can be applied tothese phases of skill acquisition, the competent nurse gen-erally has 2 to 3 years of experience in an analogous clini-cal setting.10

PROFICIENT

At the proficient level, the nurse effectively perceives theentirety of the clinical situation. Rather than respondingto aspects of patient care, this level of clinician usually isguided by substantial practical experience, an understand-ing of the key principles of nursing, and basic humanneeds. The proficient nurse has an experienced-based abil-ity to recognize nuances in clinical situations and can iden-tify when the expected normal picture does not occur. Aholistic understanding of clinical situations provides theproficient nurse with the ability to make clinical decisionswithout the need to consult learned rules or proceduralguides. The proficient nurse typically has 3 to 5 years ofexperience in a given clinical setting.10

EXPERT

The expert practitioner does not rely on analytic principlesuch as rules, guidelines, or maxims to connect his or herunderstanding of a patient situation to the appropriate nurs-ing action. This is not to say that the nurse does not utilizeskilled analytical abilities when necessary. However, theexpert is a highly experienced and skilled nurse who, basedon significant experiential learning, possesses an intuitivegrasp of clinical situations. This nurse performs in the clini-cal setting with certainty, fluidity, and flexibility. The expertnurse operates from a deep understanding of the total situ-ation, which allows for rapid identification and responseto individual patient situations. Not all nurses will becomeexperts, and there is no time frame in which a nurse gen-erally reaches this level of skilled performance.10

Purpose of Review

A number of manuscripts have been published detailingthe experiences of new GNs and a variety of innovativetraining methods that have demonstrated the potentialfor improving GN role transition and work place satisfac-tion during the first 6 to 18 months of employment.11 Thepurpose of this literature review is to examine and interpretwhat is known about the GN role transition from noviceto competent practitioner in the acute care setting. Addi-tionally, implications for nursing education practice inthe postlicensure setting will be explored.

Methods

Initially, this review was intended to be written as a synthe-sis of the literature published regarding the lived experienceof new GNs in the emergency setting. However, the authorwas unable to locate any published studies that specifi-cally address the transition from novice to competent in

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emergency nursing practice. Therefore, the literature reviewwas expanded to include all publications that specifically focuson the GN experience, new graduate training program effec-tiveness, and innovative approaches to facilitating the tran-sition from new graduate to competent nurse.

The literature review for this article was conducted uti-lizing a systematic review of the literature relating to post-licensure clinical education and the lived experiences of theGN. The literature review was conducted between Marchand June 2007 using the following publication databases:Medline, CINAHL, SCOPUS, and ProQuest Disserta-tion Database. The period used for this literature reviewincluded 1980 to 2007; however, publications selectedfor review were limited to the period ranging from 1995to 2007. The following are key search terms included inthis literature review: graduate nurse combined with educa-tion, novice, advanced beginner, training, orientation, emer-gency, experience, competency, qualitative, and transition.

The literature review initially identified 63 articles, ofwhich 21 were directly related to new graduate postlicen-sure clinical education or the lived experiences of the GN,and contributed to the body of knowledge regarding thenovice to competent transition in nursing practice. Thesearticles were read multiple times and classified in 2 ways.First, the articles were categorized into 3 types: postlicen-sure training program evaluation, GN experiences, and de-scriptions of innovative educational programs. Second, thearticles were classified according to the study methodologyutilized, if applicable, resulting in 4 categories: qualitativestudy, quasi-experimental study, descriptive study or ques-tionnaire, and study design not applicable. Articles werecategorized as follows:

1. Postlicensure training program evaluation: N = 102. GN experiences: N = 73. Descriptions of innovative educational programs: N = 4

Study methodology for the papers reviewed includedthe following:

1. Qualitative study: N = 62. Quasi-experimental study: N = 23. Descriptive survey or questionnaire: N = 104. Study design not applicable: N = 3

While this article cannot be classified as a meta-synthesisof the research because non–research-related publicationsare included in the review, the analysis method chosen foridentifying themes and interpreting the literature was Noblitand Hare’s meta-ethnographic comparative review.12 Thismethod was selected because it allows the reviewer to “com-pare and analyze text, creating new interpretations in theprocess” (p. 9).12

Trends in the Literature

A comprehensive review of the literature revealed 6 majorthemes. These themes can be collectively categorized into2 groups: culture shock (barriers to success) and assimilation(facilitators of success). Three of these themes relate di-rectly to new graduate discomfort and dissatisfaction in theacute care settings: work environment, stress/frustration,and inadequate preparation for entry into practice. The re-maining 3 themes have been identified as facilitators oftransition to competent clinical practice: mentoring, socialsupport, and orientation process.

CULTURE SHOCK

Newly graduated nurses enter the workforce enthusias-tically, eager to learn, and hoping to assimilate into thehealth care team.2-4,6,7 Often, these neophyte nurses ex-perience culture shock as they transition from the aca-demic environment to the acute care setting. Most ofthese nurses have never carried a full patient load or dealtwith the realities of professional nursing practice.13 A re-view of the literature suggests it is common for GNs tofeel inadequately prepared for what to expect when theyenter professional nursing practice, which results in cultureshock and challenges in assimilating into the institutionalculture.2-7,13-15 The following themes represent barriersto successful transition into practice and enculturation forthe GN.

Work environmentThe work environment and norms of professional nursingpractice are not what many GNs expected when they enterthe workforce. Most nurses expressed frustration with theirwork environment, including unsupportive workplace cul-ture (particularly related to socialization and treatment bypeers), high nurse-to-patient ratios, and workplace condi-tions that inhibit their ability to provide the level and typeof care that they have been taught is required of a “good”nurse.2-7,14,15 Because there is a divergence between thenursing practice experienced in an academic clinical rota-tion and institutional expectations experienced in the acutecare setting, new GNs are faced with having to learn howto be a nurse and function within an unfamiliar, sometimesunsupportive organizational culture, while being asked toassume increasing levels of responsibility.6

Stress and frustrationA common theme identified in all of the literature reviewedemphasized the stress that GNs experience when transi-tioning to professional nursing practice. While the newwork environment and feelings of inadequacy are elementsof the high level of stress experienced by novice and advanced

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beginner nurses, other stressors have been identified in theliterature. Additional sources of stress include: (1) fear ofindependent practice (worried about knowing what to doand how to respond to patient needs); (2) dealing withnew situations5-7,14; (3) work schedule challenges, dissatis-faction, or both,2,5,14; (4) unclear expectations15; and (5)finances and student loans.5

According to Casey et al,5 who conducted a descrip-tive survey study of 270 new GNs working in 6 acutecare facilities, 41% of GNs were dissatisfied with theirwork schedules, 39% were unhappy with their salary,and 40% believed that they had a lack of opportunitiesfor career development. These data are especially tellinggiven the reality that retention of GNs is historically poorand increasingly costly.5

Inadequate preparationA review of the literature indicates that there are severalareas in which new GNs do not feel adequately preparedfor professional nursing practice. Overall, a feeling of alack of self-confidence was identified by nurses in nearlyall of the studies reviewed.2-7,14,15 Specific areas that havebeen identified from the research as areas in which GNsfelt unprepared include particular nursing procedures,5-7

death and dying,5-7 organizational skills and time manage-ment,2,3,5-7 inability to recognize subtle changes in patientcondition,3,14 and communication with physicians andpatient families.5-7 Specific procedures that GNs mostfrequently cited as challenging include cardiopulmonaryarrest management, caring for patients with chest tubes,and the insertion and maintenance intravenous, central,and epidural lines.5

ASSIMILATION

Facilitation of assimilation into the nursing practice cul-ture is recognized by the literature as a major indicatorof novice and advanced beginner success in the clinicalsetting.2-7,13-17 Common themes in the literature relatedto GN assimilation include mentoring, social support,and orientation.

MentoringMentoring by more experienced nurses, often occurringthrough the use of clinical preceptors, is a consistent themein the literature. GNs indicate that the role of their pre-ceptor and the quality of the mentor-mentee relationshipare defining factors in the development of self-confidenceand clinical competence.2,5-7,13-19 To facilitate the syn-thesis of findings in the literature, the terms mentor andpreceptor are used interchangeably in this article, althoughit is important to note that these terms are not synon-

ymous. The following theme-based factors have beenidentified as promoting GN assimilation in the acute carepractice milieu:

1. Preceptors should be carefully selected and trained toensure that they have the skills and desire to effectivelymentor novice and advanced beginner nurses.2,5,10,15,16,20

2. GNs should be paired with mentors who can provide socialsupport, nurturing, and clinical guidance at an appropriateskill and performance level.5,6,10,15

3. GNs need adequate time with a consistent preceptor tofacilitate the development of a worthwhile relationship.Specifically, mentoring should be long-term and ideally,the preceptor and GN should work the same schedule toprovide continuity in the experiential learning process.5,16,19

Social supportSocial support in the clinical setting expands upon theprevious theme of mentoring to include the socializationprocess experienced by the GN. In the context of the GNexperience, social support refers to encounters with peers,the health care team, and administrative support. Recogni-tion that the first 3 to 12 months in nursing practice fre-quently is the most stressful and challenging time ina nurse’s career includes creating a caring and supportiveenvironment that allows the GN to successfully acclimateto the acute care culture. Specific social support interven-tions that have been acknowledged as facilitators of successinclude the following:

1. Providing education for practicing nurses about cultureshock and the experiential learning needs of nurse gradu-ates upon entry into practice. This preparation of stafffacilitates the enculturation of new graduates on the nurs-ing unit.5,10,16,19,21

2. Providing formal and informal opportunities for socializa-tion into the professional role.16,17,21,22

3. Managers and educators must establish clear expectationsfor the GN and preceptor while accounting for and provid-ing support in the management of scheduling adjustments(from the academic to health care setting), intensive learn-ing, and professional growth.16,20

Orientation processThe lack of congruence between hospital needs and theneeds of GNs has resulted in reported median turnoverrates for GNs during their first year of employment thatrange from 35% to 60%.5 To improve recruitment andretention of GNs, many hospitals are initiating innovativeorientation and training programs intended to facilitate thetransition among GNs from novice to competent duringtheir first 12 to 18 months of employment.11

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A number of studies have been conducted to evaluate theimpact that nurse internships, residency programs, and en-hanced orientation programs have on the GN transition fromstudent to competent nurse.19,22-25 The current researchin this area indicates that the GNs require an orientationprocess that is based on their individual needs assessment.24,26

Further, there is evidence that nurse residency programs havea positive return on investment by decreasing GN turnover,increasing job satisfaction, and effectively producing compe-tent and confident nurses.16,18,22,24,26 Although there is notemplate for the amount of orientation that an individualnurse requires to transition to competent practitioner, theliterature suggests that a minimum of 6 months to 1 yearof combined training and mentoring is required for GNsto feel confident in their ability to provide competent nurs-ing care.5,16,19,21,25-27

Implications for Emergency Nursing Education

There are several implications for ED managers and clinicalnurse educators that can be extrapolated from the litera-ture. First, the impact that preceptors and mentors haveon the GN transition in the acute care setting is profound.The importance of a detailed selection and preparation pro-cess for preceptors to ensure that they have the skills anddesire to effectively mentor novice and advanced beginnernurses cannot be minimized.

Second, emergency nurses and nurse managers in theacute care setting need education about experiential learn-ing and the lived experiences of GNs so they can providesocial support and assist in assimilation. Nurse managersplay an important role in the successful development ofnovice nurses and can address the known stressors andfrustrations that may be experienced during entry intopractice. Further, although nurse residency programs re-quire significant resource investment, the literature clearlydemonstrates that the return on investment makes theseprograms an important part of addressing the educationaland socialization needs of GNs while attending to the re-cruitment and retention issues faced by U.S. hospitals.

Finally, opportunities exist for improved collaborationbetween academic and hospital settings. Innovations suchas the implementation of summer extern programs andenhanced clinical experiences can be instrumental in GNacclimation to the acute care setting.13 Joint partnershipsbetween schools of nursing and clinical practice settingscan facilitate the development of educational programsthat better support the development of competency inemergency nursing practice by identifying gaps in experi-ence and preparation.26 Additionally, these partnershipsprovide a forum to discuss the content and breadth of

education provided at both the prelicensure and postlicen-sure level.

Conclusion

Nurse educators struggle on a daily basis to find a bal-ance between addressing the need to rapidly integratenewly graduated nurses into the acute care practice milieuwhile ensuring that these novice nurses are appropriatelysupported during the transition to postlicensure indepen-dent nursing practice. This review of the literature providesa summary of how the transition along the novice to expertcontinuum can be facilitated utilizing existing theory, prac-tice, and research examples.

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