Simulation: Smoothing the transition from undergraduate to new graduate

Transition to practice can be challenging and stressful for newly graduated nurses who are trying to adapt to a new workplace culture and fulfil role expectations (Laschinger et al., 2016; Parker, Giles, Lantrey, & McMillan, 2014). Mastering time management and multitasking in complex environments can be daunting for new nurses, with literature suggesting they can be left feeling insecure and vulnerable (Stump, Husman, & Brem, 2012). These feelings are exacerbated by inexperience, shortfalls in essential knowledge, or inadequate support networks, either real or perceived (Laschinger & Fida, 2014; Pascale Blakey & Jackson, 2016; Wolff, Regan, Pesut & Black, 2010). If left unresolved, stress levels can escalate. The resulting low levels of self-efficacy and failure to thrive in the demanding clinical environment may lead those impacted to leave the profession (Laschinger & Fida, 2014). New nurse attrition is a global phenomenon that not only impacts nurses on a personal level (Laschinger & Fida, 2014) but also impacts institutional reputation, efficiency, and budgets (Duffield, Roche, Homer, Buchan, & Dimitrelis, 2014; Li & Jones, 2013). The loss of new nurses incurs both direct and indirect costs to the institution, including the recruitment, training, and support of replacement staff, and the employment of interim casual staff to cover workload during the recruitment process (Duffield et al., 2014). High turnover rates also impact the quality of care, patient safety, and organisational reputation (Ulrich et al., 2010). Low levels of self-efficacy in newly graduated nurses create a vulnerability that can result in poor performance, the omission or delay of care, and an increased risk of errors, putting patients and nurses at risk (Stump et al., 2012). One example of this can be seen during medication administration, where there is a direct correlation between low levels of self-efficacy and poor medication calculation performance (McMullan, Jones, & Lea, 2012). Medication administration involves more than just medication calculation; numerous predictable and unpredictable issues create vulnerability to errors throughout the administration process (Hayes, Jackson, Davidson, & Power, 2015). Medication administration is a complex skill for undergraduate and newly graduated nurses to master and is often subject to interruptions (Hayes, Power, Davidson, Daly, & Jackson, 2015). The dynamic and complex environment of clinical practice compounds the risk of errors occurring (Hayes, Power, et al., 2015). Newly graduated nurses with limited clinical experiences on which to draw can be derailed easily by the interruptions they face in the clinical environment. Understanding the complexities of interruption management and having the ability to implement appropriate strategies to address these comes with experience. Along with the increased risk of error, interruptions have also been shown to increase the time taken to administer medications (Cooper, Tupper, & Holm, 2016). These compounding factors result in decreased efficiency (Cooper et al., 2016), which may place added stress on both administering nurses and those working alongside them. Providing educational experiences that will expose nurses to realistic clinical scenarios at an undergraduate level is one way of increasing experiential knowledge, improving the transition to practice. Well planned, realistic, simulated clinical scenarios and environments in areas such as medication administration have been directly linked to error reduction both in university environments and during clinical practicum (Jarvill et al., 2017; Sears, Goldsworthy, & Goodman, 2010). Pedagogical approaches such as immersive simulation experiences provide an opportunity for participants to reflect in and on action, and display attributes of critical thinking, new knowledge and skill acquisition, and strategy development (Aggar & Dawson, 2014; Kaddoura, 2010). These experiences can provide consistency in training and assessment, are easily accessible, and afford clinical benefits by reducing patient risk (Lateef, 2010). Nurses who have participated in targeted immersive simulation experiences report improved levels of self-efficacy, knowledge and skill acquisition (Hayes, Jackson, Davidson, Daly, & Power, 2017; Howard, Englert, Kameg, & Perozzi, 2011; Lubbers & Rossman, 2016; Mould, White, & Gallagher, 2011). These types of initiatives provide opportunities to smooth the transition process. Although the transition process begins at university level, ensuring practice readiness is not the domain of the tertiary education sector alone. Ulrich et al. (2010) note that the “need to assure an ongoing supply of competent RNs who are prepared to practice in acute care settings and who will remain in those settings requires a change in how new graduate nurses are transitioned into professional nurses” (p. 364). Literature has identified gaps between undergraduate education and clinical practice (Benner, Sutphen, Leonard, & Day, 2010). One method of addressing these gaps for undergraduate nurses transitioning to registered practice is through the use of carefully linked, targeted simulation experiences. Educational innovations that regularly expose students to a range of challenging environments, incorporating suitable levels of propositional, procedural, personal, and/or intuitive knowledge are required to support and assess undergraduate nurses for practice readiness. Linking undergraduate learning experiences to new graduate transition programmes is complex, requiring strong collaborative relationships between educational facilities, nurse managers, experienced clinical nurses, and hospital administrators. Undergraduate education and new graduate programmes and support processes vary globally. In the Australian context, universities are largely responsible for the task of preparing undergraduate nurses for practice, with hospital-based registered nurses and nurse managers playing a significant role during clinical practicum (Wolff, Pesut, & Regan, 2010). Transition programmes are typically the domain of the institution or the area health service by which each new graduate is employed. Several studies have researched the effectiveness of hospital-based transition experiences and programmes for newly registered nurses (Patterson, Mnatzaganian, & Boyd, 2017; Regan et al., 2017), and others for undergraduate students in preparation for scheduled clinical practicum experiences (Nielsen, Noone, Voss, & Mathews, 2013). There remains a paucity of studies that report university and hospital-based educators working in partnership to formulate programmes that flow seamlessly through from undergraduate to new graduate programmes. Clinically based nurse mangers and educators are the crucial link between university and clinical educational experiences. They are in a unique position to champion the use of a range of linked, relevant simulation experiences for new graduates as they transition to practise as registered nurses. If healthcare providers are serious about smoothing the transition in order to minimize errors, improve patient safety, and facilitate nurse wellbeing and staff retention, it is necessary to establish collaborative partnerships between undergraduates and new graduate transition programmes. The complex matrix of factors that impact transitioning undergraduate nurses into the real world of clinical practice as graduates who are able to build on previous experience, fulfil workplace expectations, and feel supported in their practice, is significantly affected by the authentic leadership of nurse managers. It is incumbent on nurse managers and experienced clinical nurses to ensure newly graduated nurses are abreast of not only how the organisation in which they work functions but also how they, as novice practitioners, fit in and effectively function within it. A consultative approach between university educators and external stakeholder groups during the design and application of nursing education programmes, curriculum development, and delivery is vital when attempting to maximize student nurse clinical practice readiness for transition to registered practice (El Haddad, Moxham, & Broadbent, 2013). Increasing the number of immersive simulation experiences designed in collaboration with transition programme coordinators before each clinical placement, which follow through to the post-graduate year, may well provide a life raft to novice nurses, reducing the risk of error and enhancing the provision of safe patient care.