While new graduate nurses (NGNs) await their first job with eagerness and anticipation, the transition from student to novice nurse can be stressful (Van Camp & Chappy, 2017). NGNs often have an idealistic view of nursing compared with the reality of providing complex patient care. Globally, the role expectations and demanding workloads of NGNs lead to reality shock, stress, and nursing turnover (Crimlisk et al., 2017; Walsh, 2018). Unfortunately, NGNs represent the largest number of nurses exiting the profession (Van Camp & Chappy, 2017; Nursing Solutions Inc.[NSI], 2018); 17% to 30% of new graduate nurses quit their initial job within the first year (Twibell et al., 2012). These turnovers cost the average hospital $4.4 million – 7 million annually (NSI, 2018). Since NGNs comprise almost ten percent of the nursing staff (Walsh, 2019), it is imperative that NGN successfully transition from student to registered nurse (RN).

Background

NGNs resign due to stress and burnout related to poor communication with patients or team members, limited critical thinking skills, the inability to interpret and adapt to changing situations, workload, unusual patient presentations, lack of recognition, and rotating medical residents (Crimlisk et al., 2017; Song & McCreary, 2020) Nurse executives report that only 10% of NGNs were fully prepared for safe practice, while the remaining NGNs lacked confidence and adequate nursing skills to do their jobs appropriately (Van Camp & Chappy, 2017).

Communication and Collaboration Skills

The need to improve communication and collaboration skills in NGNs is well documented (Crimlisk et al., 2017; Twibell et al., 2012). A review of 16 empirical studies from seven countries published between 1993 and 2018 focused on NGNs ' self-assessment or perceptions of their competencies and found that nurses were relatively confident in their "hard skills," (considered the psychomotor and cognitive domains of basic patient care), compared to the "soft skills," which included communication, teamwork, and collaboration within an interprofessional team (Song & McCreary, 2020).

NGNs are particularly vulnerable to increased stress, isolation, and dissatisfaction with their job due to poor communication and teamwork with other healthcare professionals NGNs are particularly vulnerable to increased stress, isolation, and dissatisfaction with their job due to poor communication and teamwork with other healthcare professionals (Crimlisk et al., 2017; Perron, Gascoyne, Kallakayumkal, Kelly, & Demagistis, 2019). A supportive work environment that fosters open communication, development of professional relationships, and team cohesion increases NGN job satisfaction and retention (Walsh, 2018; Song & McCreary, 2019). Incorporating simulation exercises into a program allows NGNs to develop communication skills in a safe and supportive environment (Walsh, 2018).

The COVID-19 pandemic complicated NGNs transition to practice. Healthcare workers on the frontlines caring for COVID-19 patients were often overwhelmed by the required increased workload and work hours, and the uncertainty that required daily adaptation (Murat, Kose, & Savaser, 2021). Survey results from 705 front-line nurses working within hospitals in 2020 revealed younger and newer nurses reported higher levels of stress and burnout as well as feeling inadequate about their nursing care (Murat et al, 2021). New nurses may not have developed their ability to manage typical stressors of their first job before the added stress from the COVID pandemic, emphasizing the importance of communication and teamwork in this group to maintain confidence and satisfaction.

Nurse Residency Programs

The Institute of Medicine (IOM), The Joint Commission, and National Council of State Boards of Nursing support the implementation of nurse residency programs (NRP) for the NGN to facilitate transition to practice (Twibell et al., 2012). NRPs are hospital-based structured transition to practice programs designed for an NGN upon completing their prelicensure education. The IOM recommends goals of NGNs include expanding NGN competencies, as well as improving retention rates and patient outcomes (National Academies of Sciences Engineering & Medicine [NASME], 2016; Crimlisk et al., 2017; Perron et al., 2019). In addition to traditional orientation competency checklists to verify skills, NRPs emphasize applying skills that integrate communication, professionalism, and development of the skills needed to work within the healthcare team (Walsh, 2018; Song & McCreary, 2020). NRPs allow peer support to help decrease NGNs’ stress as they realize that other NGNs are experiencing the same issues on their units (Twibell et al., 2012).

The Institute of Medicine (IOM), The Joint Commission, and National Council of State Boards of Nursing support the implementation of nurse residency programs (NRP) for the NGN to facilitate transition to practiceA recent review examined NRPs, job satisfaction, and retention rates and concluded that NRPs are an effective bridge between undergraduate education and practice for the NGN. With increased acuity, complexity of treatments, and technology associated with clinical practice, NRPs can improve the quality of care delivered to patients, which in turn, increases NGNs' satisfaction and retention (Perron et al., 2019). NRPs provide structure and guidance that improved NGNs' confidence, increased decision-making skills, raised their awareness of policies that ensured delivery of safe care, and created a stable workforce (Crimlisk et al., 2017; Perron et al., 2019).

Crimlisk et al. (2017) developed an NRP for NGNs working in the specialty units of a large inner city, level I trauma, academic hospital. NGNs reported a lack of confidence in clinical and communication skills and role stress. Strategies used to improve communication and clinical confidence included active engagement, incorporating competency tools, progress reports and self-directed learning with appraisal to develop clinical problem-solving skills. Problem-based education incorporated both self-directed studying and ongoing self-assessment. Program evaluations assessed clinical experience, course content, knowledge, and confidence. Further, the evaluations reported integration into professional network, which is critical for inclusion which builds confidence to work independently. Repeat surveys conducted at six months and one year after implementing the NGN, indicated NGN perceptions of safety and competency at 98% and 91% of the surveys, respectively (Crimlisk et al., 2017).

Clinical competence in nursing develops on a continuum as NGNs pursue experiences and provide safe care with the supervision and guidance from their preceptors (Walsh, 2018). Improvements in NGNs’ abilities to organize, prioritize, communicate, and provide clinical leadership increased during the 12-month NRP. However, NGNs reported a fluctuation in self-perception that was initially high, decreased at 6 months, and increased again at 12-months. NGNs’ perceptions of the support they received, as well as satisfaction, followed the same pattern of decline followed by an increase at 12-months (Crimlisk et al., 2017; Perron et al., 2019).

Purpose and Project Setting

The purpose of this project was to enhance NGNs communication skills by incorporating advocacy, teamwork, and collaboration development using simulated scenarios practiced with peers in a NRP. The project was conducted at a 404-bed inner-city academic teaching hospital in southwestern Pennsylvania. The hospital was affiliated with a large health system with Level 1 Trauma designation. The hospital hires approximately 120 NGNs annually and has an existing NRP. The turnover rate for first year NGNs was 12.52% in 2017 – 2018. The hospital offered an NRP that supplemented nursing orientation. Although this NGN turnover rate was less than the national average, the hospital was interested in improving NGN's communication and teamwork skill sets. Nurse leaders believed that NGNs lacked confidence in dealing with difficult situations which could be improved with better communication and teamwork. The hospital review board approved the project as a quality improvement project. All data collected were de-identified. There were no conflicts of interest.

The purpose of this project was to enhance NGNs communication skills by incorporating advocacy, teamwork, and collaboration development using simulated scenarios practiced with peers in a NRP. The project leader developed a team consisting of nurse leaders, NGNs within their first or second year of professional practice, nurse educator, nurse’s aide, physician, social worker, and pharmacist. Team members interviewed graduate nurses to understand their learning needs, observed sessions in the NRP to identify concerns of NGNs, and consulted with unit directors about their perceptions of the needs of NGNs’ communication during difficult situations. A gap analysis between evidence-based best practices and current practice revealed an opportunity to provide a communication program within the NRP to enhance NGN knowledge and confidence to manage challenging patients, families, and team members.

Framework

Two models guided this project. Benner’s novice to expert model (1982) provided a framework for developing expectations of NGN’s success. The model describes nurse development of skills and comprehension over time after an educational foundation. Nurse's knowledge combined with experience leads to an increasing level of competence. The competent nurse demonstrates nursing practice efficiently and confidently. The 19-step Johns Hopkins' Nursing Evidence-based Practice Model provided a framework to review the literature, plan, and implement the practice change through three processes: practice question, evidence, and translation (Dang & Dearholt, 2017).

Methods

Interventions

Learning Needs Assessment

A learning needs assessment was conducted for NGNs within the NRP during regularly scheduled residency sessions over three months in September through November of 2019. This assessment determined the frequency in which NGNs were involved in challenging situations, as well as their level of confidence in communicating with patients, families, team members, and other healthcare providers. Results from assessments of 112 NGNs indicated that they frequently encountered challenging situations with patients, families, team members, and experienced nurses and felt some confidence in managing them. NGNs recommended using an incident of a recent issue of an intoxicated visitor and how to manage conversations with the patient and family.

Educational Sessions

Two presentations were developed using the framework from the Comprehensive Unit-Based Safety Program (Agency for Healthcare Research and Quality [AHRQ], 2018) toolkit. These presentations focused on the importance of effective communication and transparency, identification of barriers to communication, and application of effective teamwork and communication tools (AHRQ, 2010). The sessions started with a 15-minute presentation on either the topic of effective communication with patients, families, and co-workers, or teamwork and collaboration with both sessions offered to all cohorts. NGNs were divided into two groups to discuss and role-play the interactions that could be used to professionally manage challenging interactions. After the group sessions, the NGNs regrouped to debrief and share their reflections of what worked, what did not work, and what could work. The presentations and case scenarios were trialed in January 2020 with 37 NGNs in the final months of their residency program. Feedback from participants following the sessions and course evaluations were used to refine the scenarios. In February 2020, the communication programs and scenarios were implemented within four NRP cohorts over eight months. Sessions were about 45-minutes in length. Participants completed a course evaluation at the end of each session. NGNs assessed the difference of knowledge and confidence level before and after the program, using a 5-point Likert scale. They also assessed the likeliness of use in practice, used two yes/no questions to ask if the scenarios were representative of their practice, benefit of the program, and general questions such as which month to offer the program, and any suggested topics.

Measures

The revised Casey-Fink Graduate Nurse Experience Survey (CFGNES) (Casey & Fink, 2006) was used to measure communication skills at the beginning of the NRP and 6 and 12 months after starting the program. The CFGNES is a reliable and valid tool widely used in clinical practice to measure NGNs' self-assessment of professional comfort and expectations or supports in five domains: support, patient safety, stress, communication and leadership, and professional satisfaction.

Communication was measured by the communication domain in the CFGNES at 6 and 12 months. The project compared four NRP cohorts in 2019 compared to four NRP cohorts in 2020. The domain of Communication/Leadership was chosen as the main outcome measure as the scenarios were designed to improve communication with patients, their support persons, and the healthcare team. One question from the support domain, “Ease of asking for help from other RNs,” was also included as communication skills are required to ask for help. The process measures for the project were the number of participants and the results of the program evaluations.

The impact of the education program was assessed by comparing the NGNs’ perceived level of knowledge presented before and after completing the activity. Evaluations were collected via paper and pencil format after live sessions or as a Google online survey for online sessions.

Results

CFGNES means between groups were analyzed using one-way ANOVA with Tukey post ad hoc tests. De-identified CFGNES results are reported as means of the cohort to the facilities and are also used for the analysis. The program evaluations were analyzed with descriptive statistics (Table 1).

Table 1. Casey-Fink Graduate Nurse Experience Survey One-Way ANOVA at 1, 6, 12 Months

*Denotes statistical significance (p<0.05)

In September, 2020 the sessions changed from in-person to synchronous online. The online format resulted in fewer NGNs attending and evaluations submitted. NGNs returned 148 (73%, n = 204) program evaluations and rated their level of knowledge before the activity an average of 3.86 (out of 5) compared to 4.36 after the intervention, a 13% increase. The NGNs level of confidence in applying communication skills increased by 14% from 3.86 to 4.41 after the program. The average rating for likely to use the knowledge gained during the session was 4.75, out of possible 5.0, and participants recommended that the content be offered during month four of the NRP. Most participants (98%) rated the scenarios similar to their practice, and 92% responded that the scenarios were beneficial. Future topics suggested were conflict resolution and de-escalation techniques.

The CFGNES was conducted online by NGNs at 0, 6, and 12 months during the NRP. CFGNES’ overall means for the communication domain increased from 3.27 before the project to 3.45 after. Due to missing data at 6 months in one cohort in the post-implementation group, the ANOVA was run without that cohort with similar results. CFGNES scores showed a statistically significant difference between groups (F(5,132) = 90.18, p = .00000). Tukey's post-ad hoc analysis showed no significant difference at 0 months between the historical and project groups, but there was a significant increase in satisfaction scores for the project group at 6 months (p = .0007) and 12 months (p = .00000). Mean scores of Casey-Fink Graduate Nurse Experience Survey at 1 and 12 months within communication domain showed increase in all statements, particularly with the statement, “I feel confident communicating with patients and families,” which scored highest at 1 month (Table 2).

Table 2. Mean Scores of Casey-Fink Graduate Nurse Experience Survey at 1 and 12 Months

*Two statements: I feel confident communicating with patients and families, and I feel at ease at asking for help scored highest at 1 month.

Discussion

Scenarios with role-playing and debriefing offered during the NRP was a successful strategy to improve NGN confidence in the communication skills of NGNs. Pre and post-project groups had similar CFGNES scores at baseline. Within the communication domain, the project group showed a significant improvement at 6 and 12 months. Additionally, the project group showed significantly higher satisfaction at 6 months (p=.0007). The improvement at six months may have clinical implications. In a previous study, CFGNES’ results followed a pattern of declining satisfaction at 6 months that then improved by 12 months (Fink, Krugman, Casey, & Goode, 2008). Since the six-month tenure in employment is a pivotal time period for “reality shock” (Perron et al., 2019), continual improvement in the communication domain for the project group may have implications for retention, job satisfaction, and “reality shock” (Cline, La Frentz, Fellman, Summers, & Brassil, 2017; Van Camp & Chappy, 2017).

Scenarios with role-playing and debriefing offered during the NRP was a successful strategy to improve NGN confidence in the communication skills of NGNs.The improvements in communication skills in this project were achieved by providing NGNs opportunities to practice in a safe environment during role-playing and debriefing. Hall , Taylor, and Altobar (2009) and Song et al. (2020) both concluded that NGNs need to be provided with practice and support to develop assertiveness and foster teamwork within the interdisciplinary group. However, this was not the only way to develop the “soft skills” associated with communication; adding content to the NRP using role-playing and debriefing was an additional way to achieve “soft skills” such as improved confidence associated with communication.

The scenarios in this project offered participants the opportunity to practice communication and teamwork skills and resulted in improved confidence in NGN communication skills. The project leader created debriefing scripts for use by any of the NRP leaders to use, thus allowing for sustainability over time. Other centers could use a similar process to create scenarios for the needs of their NGNs. For example, a participant in the learning needs assessment recommended developing a scenario on the care of a dying patient. In the future, having a bank of scenarios that could be matched to participant learning needs would be beneficial to the learners.

Limitations

The limitations of this project are that it was conducted in one facility during COVID- 19 pandemic. It is not known what effects the pandemic had on NGNs’ confidence, although there is evidence that stress among staff nurses was high (Murat et al., 2021).

Conclusion

Communication and collaboration are necessary skills in the healthcare profession. As NGNs develop their clinical practice from novice to advanced beginner, they become more confident in their interactions with challenging patients, families, and the interdisciplinary team. Simulation using scenarios similar to those NGNs encounter in clinical practice can accelerate skill development and improve confidence, and reduce job dissatisfaction and turnover.

Authors

Jacqueline Leonard, DNP, RN, CNS

Email: jleonard@franciscan.edu
ORCID ID: https://orchid.org/0000-0002-0943-7618

Dr. Leonard is an Assistant Professor of Nursing at Franciscan University of Steubenville.She teaches Mental Health Nursing in the undergraduate nursing program.

Kimberly Whiteman, DNP, RN
Email: kwhitema@waynesburg.edu
ORCID ID: https://orcid.org/0000-0003-4932-8616

Dr. Whiteman is an associate professor of nursing at Waynesburg University. She teaches evidence-based practice in the Doctor of Nursing Practice program.

Kimberly Stephens, DNP, RN
Email: kstephens@waynesburg.edu
ORCID ID: 0000-0002-6976-0249

Dr. Stephens is an associate professor of nursing at Waynesburg University. She teaches interprofessional collaboration and team building and principles of strategic planning in the Doctor of Nursing Practice program.

Connie Henry, DNP, RN
Email: henryc@upmc.edu
ORCID ID: https://orcid.org/0000-0001-9536-8868

Dr. Henry DNP, RN is the Director of Cultural Excellence at UPMC Mercy. She teaches healthcare outcomes in the Doctor of Nursing Practice program at Waynesburg University.

Brenda Swanson-Biearmann, DNP, MPH, RN
Email: bswanson@waynesburg.edu
ORCID ID: 0000-0002-3148-5296

Adjunct Professor at Waynesburg University.