Art & science service evaluation
Provision of training and support for newly qualified nurses Jones A et al (2014) Provision of training and support for newly qualified nurses. Nursing Standard. 28, 19, 44-50. Date of submission: August 8 2013; date of acceptance: October 7 2013.
Abstract Aim To evaluate nurses’ and ward managers’ experience of the Nurse Foundation Programme (NFP), with a view to improving future programmes. The NFP was introduced in 2008 to provide newly qualified nurses with standardised training and support during their first year post-training in Cardiff and Vale University Health Board. Method Anonymous evaluation forms were analysed and interviews with nurses and ward managers were undertaken. Evaluation form data were descriptively analysed, and interviews and free text comments were thematically analysed. Findings The NFP was highly valued by attendees, offering timely knowledge and support for newly qualified nurses. Ward managers reported that the NFP made it easier to release time for newly qualified nurses to participate in training, while helping with skill mix decisions on the ward. Conclusion The centrally planned and coordinated NFP was positively evaluated and led to a standardised approach to training and support for newly qualified nurses.
Authors Aled Jones Senior lecturer, School of Healthcare Sciences, Cardiff University. Judith Benbow Lecturer and associate director of international and engagement, School of Healthcare Sciences, Cardiff University. Rachel Gidman Senior manager for nurse education, Cardiff and Vale University Health Board. Correspondence to: [email protected]
Keywords Newly qualified nurses, preceptorship, service evaluation, training, workforce evaluation
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above. 44 january 8 :: vol 28 no 19 :: 2014
IT IS ESTIMATED THAT more than half of the nursing workforce is newly qualified, therefore ensuring the smooth transition from student to qualified nurse should be a priority for nurse managers and the NHS (Whitehead and Holmes 2011). Health secretary Jeremy Hunt’s recommendation that nursing students in England work as healthcare assistants for one year before undertaking their training, focused debate on the commencement of nurses’ careers (Gillen 2013). The transformation from nursing student to registered nurse involves a change in status, role and responsibility, and this is seen as a period of uncertainty, stress and disorientation for newly qualified nurses. Kramer (1974) described how newly qualified graduate nurses experienced ‘reality shock’, characterised by the feeling that they were inadequately prepared for their new role. Equivalent experiences of newly qualified nurses are captured by Duchscher’s (2009) transition shock theory based on long-term research with nurses in Canada (Figure 1). Duchscher’s (2009) theory proposes that newly registered nurses undergo a process of physical, emotional, intellectual and socio-developmental adjustment that is motivated and mediated by changing roles, relationships, responsibilities and levels of knowledge in their personal and professional lives. Although Kramer’s (1974) and Duchscher’s (2009) work is based on the experiences of north American nurses, similar issues have been identified in studies from the UK, Australia and Ireland, with problems during transition being partly attributed to variable levels of support by employers during the initial post-qualification period (Mooney 2007, Higgins et al 2010). The transition from student to registered nurse involves a process of learning, adjustment and socialisation to the new workplace. It is important that the employer supports the newly qualified nurse through this process because early experiences in the workplace may be strong predictors of future work satisfaction, with negative early experiences potentially having a significant negative effect on future career development (Banks et al 2010, Jamieson et al 2012).
© NURSING STANDARD / RCN PUBLISHING
Downloaded from RCNi.com by ${individualUser.displayName} on Dec 03, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Preceptorship In recognition of the transition shock experienced by newly qualified nurses, healthcare organisations provide programmes of support for new staff members. For example, preceptorship programmes and online learning have been designed to assist new practitioners with the transition to registered practitioner (National Nursing Research Unit (NNRU) 2009, Jamieson et al 2012). The term preceptorship in the UK is associated with providing support for newly qualified nurses and other healthcare practitioners, whereas outside the UK, especially in North America, preceptorship is often associated with support given to nursing students. Preceptorship is defined by the Nursing and Midwifery Council (NMC) (2006) as a process that provides support and guidance, enabling new registrants to make the transition from student
to accountable practitioner. The NMC (2006) recommends that all new registrants be offered a period of preceptorship when starting employment. This is also recommended by the Department of Health (DH) (2010) in England, and the Welsh Assembly Government (2009), which advocates that nurses in Wales ‘be afforded protected learning time in their first year of practice and the support of a preceptor’. However, a review of preceptorship undertaken by the NNRU (2009) concluded that preceptorship programmes were not universally available. Furthermore, periods of preceptorship ranged from one month to more than six months, and satisfaction was greater with preceptorship of four months or longer than with shorter periods. The review also concluded that few robust studies focusing on preceptorship existed in the UK or elsewhere.
FIGURE 1 Transition shock theory Relationships
Disorientation
Transition shock
Roles
Loss
Intellectual: Reality shock – theory/practice incongruencies and practice improprieties. Lack of knowledge of transition. Lack of awareness regarding graduate roles and responsibilities. Limited practice aspect/pattern recognition. Limited tacit/practical knowledge. Practice inconsistency/unpredictability. Limited decision making and clinical judgement capacity. Organisational naivety. Professional role-relations immaturity. Limited performance feedback.
Doubt
Emotional: Labile nature of emotions. Emotions variable in origin. Intense and overwhelming period. Extreme sensitivities. Seeking validation and reassurance. Look for familiar protective nurturing. Require positive reinforcement. Fears of failure or incompetence. Fears of disappointing family, friends and colleagues. Loss of control. Lack of support.
Confusion
Socio-developmental: Changing social structures. Role uncertainty and unfamiliarity. Inadequate and insufficient guidance and/or assistance. Professional culture naiveté. Intra-interdisciplinary relations. Intergenerational dynamics. Leadership and delegation skills lacking. Oppressively hierarchical work structure. Evolving self – separation from dependent role. Loss of known supports. Insufficient exposure to role models.
Responsibilities
Physical: Relentless and terminal physical, emotional and intellectual exhaustion. Energy consumed to conceal feelings and transition responses. Physical demands of acute care Unaccustomed to full shift presence or full-time shift rotation. Emotional extremes. Maladjustments to shift work. Sleeplessness – active dreaming. Poor nutrition and lack of exercise. Change to social habits and routines.
Knowledge (Duchscher 2009)
© NURSING STANDARD / RCN PUBLISHING
january 8 :: vol 28 no 19 :: 2014 45
Downloaded from RCNi.com by ${individualUser.displayName} on Dec 03, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science service evaluation Cardiff Nurse Foundation Programme Approximately 150 newly qualified nurses are recruited by the Cardiff and Vale University Health Board (UHB) in Wales each year when they graduate from pre-registration nursing courses. A review, undertaken in 2008, of support and training offered to newly qualified nurses across the UHB found significant variation in the type and duration of training offered by hospital wards and departments. For example, some wards delivered initial orientation and induction programmes for newly qualified nurses allied to mandatory and essential training provided by the UHB, such as medicines management or infusion pump training. Other areas had no orientation or induction programmes in place, offering mandatory training courses only for newly qualified nurses. In addition, several ward managers experienced difficulties booking and releasing staff to attend mandatory or essential training because these were arranged at relatively short notice. As a result of these factors, some nurses received little or no training and support when starting their first nursing posts. The relatively small numbers of newly qualified nurses undertaking induction training in many departments was also considered an inefficient use of time and resources, resulting in duplication of effort and the potential for variation in the content, delivery and outcome of training. Following the review, a centrally designed and co-ordinated approach to training and support of newly qualified nurses was mandated by senior nursing management. Consequently, the UHB’s learning, education and development department, and a group of professional and practice development nurses, designed the Nurse Foundation Programme (NFP), which offers orientation,
TABLE 1 Comparison between the previous training and support regimen and the Nurse Foundation Programme Previous training and support
Nurse Foundation Programme
Variable access to training and support offered to newly qualified nurses.
Training and support undertaken by all newly qualified nurses.
Variable content and outcomes of training offered.
Standardised content and outcomes of training.
Duplication of effort because training and support activities existed in isolation with no co-ordination.
Efficient use of resources, with two groups per year being trained and supported.
Mandatory training events arranged at short notice, resulting in ward managers experiencing difficulties with booking and releasing time for staff to attend.
Central booking system, with training events arranged at least three months in advance.
46 january 8 :: vol 28 no 19 :: 2014
induction, and training and support. The first NFP cohort began in October 2008, and two cohorts per year (in October and April) have participated in the NFP since that time; 577 newly qualified nurses have completed the programme to date. The NFP comprises 13 study days that span the nurse’s first year of employment. The content of the programme is based on mandatory requirements, as well as some basic and essential skills and knowledge that were not included, or only partially covered, during pre-registration nurse education. The study days cover topics such as infusion pump workshops, medicines safety and management, intravenous (IV) drug administration, mentorship, and documentation and legal issues. The study days are arranged in advance, providing ward managers and NFP attendees with sufficient opportunity to arrange time off work to attend. All nurses undertaking the NFP are allocated a nurse preceptor, an individual who helps support the learning and developmental needs of the newly qualified nurse during this period of adjustment. Details of the changes introduced by the NFP are shown in Table 1.
Ethics The project proposal to evaluate nurses and ward managers’ experience of the NFP was reviewed and deemed to be a service evaluation by the Cardiff and Vale UHB Research and Development Committee, therefore ethical approval was not required. The service evaluation project plan was reviewed by Cardiff University’s School of Nursing and Midwifery Studies Research Review and Ethics Screening Committee.
Aim The aim of the service evaluation was to: Describe interviewees’ assumptions, expectations and experiences of the programme. Present interviewees’ opinions about the structure and content of the programme. Use the outcomes of the evaluation to plan future programmes.
Method Since 2008, the NFP has been evaluated anonymously via an evaluation form designed by the NFP team. The form consists of a numerical rating scale indicating the usefulness of the programme, ranging from 0 (no use at all) to 10 (extremely useful). Free text boxes also appear on the evaluation form, asking for written feedback on the perceived usefulness or lack of usefulness of various programme elements. These data were
© NURSING STANDARD / RCN PUBLISHING
Downloaded from RCNi.com by ${individualUser.displayName} on Dec 03, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
accessed and collated from 212 evaluation forms. While data on the evaluation forms were available, it was decided to undertake a more detailed assessment on the fifth anniversary of the NFP’s inception. As a result, interviews were undertaken with attendees who had completed the course and with ward managers who arrange for newly qualified nurses to attend the NFP (Table 2). Interview participants received an information letter about the evaluation at least two days in advance of being recruited, which explained that data collected were to be held confidentially and the identities of participants were to be anonymised. To minimise any sense of coercion to participate, information and invitations to take part in the interviews were delivered in the following ways: NFP attendees – information sheets, posters and letters were displayed in clinical areas where nurses work who were attending or had completed the NFP. Interested individuals were directed to email or telephone to arrange a date and time for interview. Members of the NFP and/or learning, education and development department team were not involved in the direct recruitment of participants, minimising any sense of coercion or threats to the independence of the evaluation. All recruitment and interviewing was undertaken by two of the authors, (AJ and JB), from Cardiff University, who were commissioned to undertake the evaluation. Ward managers – invitations to participate in the evaluation were distributed to ward managers via hospital email. Times, dates and locations for the interviews were arranged with managers who indicated their willingness to participate. Interview schedules (which may be requested via email) were designed to ensure that any areas of common interest were discussed within, and where relevant, between the different interview groups. For example, interviewers were interested in whether similar views about the usefulness of the NFP were common to ward managers and NFP attendees, as well as different areas of clinical practice. Interviews lasted 45 minutes on average.
Data analysis
Following transcription of the interviews, content and thematic analysis of the interview data and free text comments on the evaluation form was undertaken by two members of the evaluation team (AJ and JB) who had no involvement with the day-to-day planning or running of the NFP. Although the authors were mindful of the aims of the study, any unanticipated themes that emerged
© NURSING STANDARD / RCN PUBLISHING
from the data analysis were also considered (le May and Holmes 2012). Descriptive quantitative analysis of routinely collected evaluation forms added comparative data.
Findings Evaluation forms
The NFP was evaluated positively by NFP attendees who had completed the evaluation form; mean usefulness score of 8 out of 10, with all cohorts averaging a usefulness score of at least 7.5 out of 10. Written comments in the free text boxes also demonstrated that newly qualified nurses valued the support provided by the NFP. Particularly beneficial was the opportunity to interact and share learning with others who were newly qualified during a ‘key year’, as described by one participant (Box 1). The NFP was also described by attendees as being well organised. Less positive comments related to late cancellations and changes to scheduled training sessions, although these incidents occurred mainly because of speakers
TABLE 2 Clinical areas and number of participants who took part in semi-structured interviews on fifth anniversary of the NFP Sample
Clinical area and number of participants
Nurse Foundation Programme attendees (2009-2012) (n=15)
Acute general medicine (n=5), mental health (n=3), paediatrics (n=2), surgery (n=5)
Ward managers (n=5)
Acute general medicine (n=2), mental health (n=1), paediatrics (n=1), surgery (n=1)
BOX 1 Examples of positive and negative comments in free text boxes Positive comments: Very useful. Enjoyable, NFP is really good. Very helpful. Excellent. Really good to see other newly qualified nurses going through same experiences. Great support, good to meet other newly qualified nurses. Valuable training for newly qualified nurses. Excellent lectures, more up-to-date than university. Very well planned, good content, informative. Great structure – good to know in advance to arrange shifts. Thank you for support and guidance in a key year. Negative comments: Useful, however, some things repeated from university. Some classes need to be more specialist for paediatric nurses. Mental health-specific days would help. No prior notice of speaker not turning up. Qualified nine months ago and would have liked this sooner.
january 8 :: vol 28 no 19 :: 2014 47
Downloaded from RCNi.com by ${individualUser.displayName} on Dec 03, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science service evaluation being unable to attend for a variety of reasons. One frequently raised issue was the need for more training sessions to be dedicated to newly qualified mental health and children’s nurses. Recommendations by participants included scheduling the IV drug administration training sessions earlier in the programme, being awarded a certificate to signify completion of the NFP, including IV cannulation, and delivering content via an online platform.
Semi-structured interviews
The data collected during interviews were analysed and the following themes were identified: Support for newly qualified nurses and ward managers. Programme organisation. Recommended changes to the NFP. Support for newly qualified nurses and ward managers Echoing some of the comments in the free text boxes, several newly qualified nurses described how supportive the programme was during transition from student to newly qualified nurse. In particular, the 13 study days afforded an opportunity for nurses to share and learn from their colleagues’ experiences in a supportive and non-threatening environment. One interviewee commented that: ‘everyone talks about how they feel which gives me confidence’ (NFP attendee 7). Even though a training session would provide instruction on a technical skill, such as placement of a nasogastric tube, the discussion and support would often extend beyond the particular procedure: ‘So, the study days not only help me to be confident with doing sometimes difficult things like IVs or NG tubes, but it also really helps to see that I’m not the only one struggling or asking stupid questions about these things. When we get into discussions around our tables everything gets talked about, like off-duty problems, hassles with ordering uniforms as well as the stuff they are trying to teach us’ (NFP attendee 12). Even though the NFP offered support, the impact of being a newly qualified nurse was also apparent: ‘The programme does help with coming to terms with the change in role, but nothing can really prepare you for the responsibility you feel’ (NFP attendee 3). ‘It helps that I’m on the programme and that the ward is supportive, but I still sometimes panic at the thought of being in charge of patients’ (NFP attendee 9). 48 january 8 :: vol 28 no 19 :: 2014
Ward managers also discussed how they were supported by the NFP: ‘It’s less work for me now compared to trying to book different courses and balance the off-duty’ (Ward manager 2). ‘Since having the NFP it’s easier to plan the skill mix. I now know where the newbie [new] nurses are in terms of having had certain training at certain times. Before it was a lot more haphazard with things being cancelled at short notice’ (Ward manager 3). ‘Yes it definitely helps me plan shifts when I know that say three months in they will be up to speed with [infusion] pump training’ (Ward manager 4). Programme organisation Ward managers also appreciated the support of having a centralised and co-ordinated approach to organising the NFP: ‘Used to be tough getting them on to mandatory training, never enough notice given, but now I know well in advance when the study days are going to be and they [nurses] will come back knowing what they need to’ (Ward manager 3). ‘It’s good to know when we have someone new starting that there’s one less thing to organise like meds [medicines] management or updating mandatory training… I’m able to roster much better also and it gives the new band 5s a bit of protection time wise. It’s good that it doesn’t matter where you are in the UHB you know that all the new band 5s have had more or less the same initial training’ (Ward manager 1). The attendees described having study days organised in advance as a ‘godsend’ (NFP attendee 9) and ‘just what is needed when you are new ‘cos you don’t want to apply and organise study leave straight away’ (NFP attendee 1). The NFP is seen as offering equal opportunity to participate since it ‘doesn’t matter where you are in the UHB’ (Ward manager 1) everyone is entitled to attend regardless of ability to gain approval for study leave funding and/or time. Recommended changes to the Nurse Foundation Programme Interviews and comments in free text boxes would often indicate areas where the NFP could be further improved (Box 2). All suggestions have been taken into consideration by the NFP team. For example, suggestions for more specific content for different fields of nursing and earlier coverage of medicines management and IV drug
© NURSING STANDARD / RCN PUBLISHING
Downloaded from RCNi.com by ${individualUser.displayName} on Dec 03, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
administration have led to changes in the NFP timetable. Providing more information about career development, and education and training opportunities following completion of the NFP, was included in the programme for the October 2013 cohort. Increased use of online learning content requires further exploration to assess feasibility in terms of content development costs and access to personal computers in the workplace. Further steps are planned for closer working between the end of third-year training at the local university and the NFP, for example to ensure that recent content from the undergraduate programme is not repeated unnecessarily. However, not all newly qualified nurses recruited into the UHB are trained locally, although most are, which means closer working may only improve the programme for some participants.
Discussion The results of the evaluation are limited because not all NFP attendees completed the evaluation forms (n=212) and a relatively small number of interviews were undertaken in one area of the UK only. This may have led to bias because the forms may have been completed only by those attendees who were generally satisfied with the course. However, this seems unlikely because the forms were anonymous to encourage candid feedback, and negative comments and ratings appear in the forms that were made available to the evaluation team. Although the NFP was initially conceived as a means of co-ordinating and centralising the training offered to newly qualified nurses, it is clear that nurses benefit from the support of colleagues undertaking the NFP. This positive unintended consequence seems to occur naturally from gathering a group of nurses together who are undergoing a period of profound change, or reality or transition shock. Similar findings were discussed by Banks et al’s (2010) evaluation of the Flying Start NHS programme in Scotland, who reported that ‘supervisor support to newly qualified nurses is crucial during this period’. The face-to-face contact and support opportunities afforded by the NFP were of benefit to attendees, and to the organisation, since newly qualified nurses who feel supported are more likely to adjust better to the demands of their role (Lauder et al 2008, DH 2010). The co-ordinated and standardised approach to training was appreciated by ward managers who viewed the NFP structure as less ad hoc than before. Morgan et al (2012) found that more, rather than less, structure is preferable for such programmes. The practical implications of the NFP structure, namely that ward managers have a better
© NURSING STANDARD / RCN PUBLISHING
BOX 2 Areas for improvement in the Nurse Foundation Programme More specific content for children’s and mental health nursing. Medicines management, infusion pump training and intravenous drug administration content to be delivered earlier in the programme. Increased use of online learning. Increased links with nurse training in local higher education institution, particularly near the completion of training. More information about career development, and training and education opportunities beyond the programme.
understanding of the skill set of newly qualified nurses, makes decisions about patient allocation and skill mix easier to manage. For example, ward managers now know that newly qualified nurses are competent in IV drug management and administration within six months of qualifying, whereas before the NFP those nurses may or may not have attended the relevant study day within the first six, or even 12 months. The NFP means that ward managers know which newly qualified nurses have the relevant skill set or competencies and at what point during their first year following registration. This is a consequence that has not been discussed elsewhere in the literature in relation to newly qualified nursing programmes. Planning the programme has solved the problem of time release experienced elsewhere with similar programmes (Lauder et al 2008). However, some occurrences of non-attendance remain because of the need to cover shifts, although this is an exception. The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) recommended that nurses demonstrate up to date learning on an annual basis, consisting of documented evidence of recognised training and wider relevant learning. The NFP goes some way to meeting this requirement because it provides documented learning opportunities in a supportive environment. Further recommendations, such as the demonstration to commitment, compassion and caring evidenced by patient and family feedback, is not explicitly present in the NFP and is an area for future consideration and inclusion. Suggested areas for improvement that were raised via interviews and written feedback have been implemented, or are in the process of being realised. More field-specific training is now being provided for children’s and mental health nurses, while the joining up of the NFP with future learning opportunities, such as leadership and preparing to manage courses, is soon to be implemented by giving newly qualified nurses a clear understanding of the progressive learning on offer via the learning, education and development january 8 :: vol 28 no 19 :: 2014 49
Downloaded from RCNi.com by ${individualUser.displayName} on Dec 03, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science service evaluation department. This final point evokes a pertinent discussion within the Willis Commission on Nursing Education (2012) report, which described nurses’ competence and confidence as ‘part of a journey with various landmark stations, and not a fixed end point’. Thus, while the NFP provides those nurses at the threshold of their careers with a firm grounding, there is also the recognition that within the context of their careers the availability of a series of learning opportunities, rather than a single programme of learning, is required.
Conclusion Difficulties associated with the transition from nursing student to newly qualified nurse suggest that it is important to focus on the way in which practitioners commence their nursing careers. Although transition is a challenging time for nurses, the evaluation of the NFP demonstrated that its centralised, co-ordinated and supportive nature is highly regarded by newly qualified nurses and ward managers. The programme is a work in progress
and suggested areas for improvement have and are being implemented. Although the benefits to the UHB were not directly measured or captured, there is a clear link between high-performing organisations and maintaining a workforce that considers itself supported and valued NS
IMPLICATIONS FOR PRACTICE A centrally planned and co-ordinated approach is important when supporting newly qualified nurses. Newly qualified nurses appreciate the support and learning opportunities provided by the Nurse Foundation Programme (NFP). Making the NFP obligatory provides an equal opportunity for training and support for all nurses, regardless of the clinical setting. A standardised programme means ward managers and others have an up-to-date understanding of the skill set of newly qualified nurses. Ward managers felt that the NFP made it easier to release time for newly qualified nurses to participate in training.
References Banks P, Kane H, Roxburgh M et al (2010) Evaluation of Flying Start NHS. Final Report. tinyurl.com/ kkmp93y (Last accessed: December 12 2013.) Department of Health (2010) Preceptorship Framework for Newly Registered Nurses, Midwives and Allied Health Professionals. The Stationery Office, London.
experiences and perceptions of the newly qualified nurse in the United Kingdom. Nurse Education Today. 30, 6, 499-508. Jamieson L, Harris L, Hall A (2012) Providing support for newly qualified practitioners in Scotland. Nursing Standard. 27, 2, 33-36.
Gillen S (2013) Ministers ‘take a slug’ at the RCN for slamming HCA plan as ‘stupid’. Nursing Standard. 27, 34, 6.
Kramer M (1974) Reality Shock. Why Nurses Leave Nursing. Mosby, St. Louis MO. Lauder W, Roxburgh M, Holland K et al (2008) Nursing and Midwifery in Scotland: Being Fit for Practice. The Report of the Evaluation of Fitness for Practice Pre-Registration Nursing and Midwifery Curricula Project. tinyurl.com/lvelzut (Last accessed: December 12 2013.)
Higgins G, Spencer RL, Kane R (2010) A systematic review of the
le May A, Holmes S (2012) Introduction to Nursing Research.
Duchscher JEB (2009) Transition shock: the initial stage of role adaptation for newly graduated registered nurses. Journal of Advanced Nursing. 65, 5, 1103-1113.
50 january 8 :: vol 28 no 19 :: 2014
Developing Research Awareness. Hodder Arnold, London.
the Components of Success? King’s College London, London.
Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Executive Summary. The Stationery Office, London.
Nursing and Midwifery Council (2006) Preceptorship Guidelines. NMC Circular 21/2006. tinyurl. com/35go2r6 (Last accessed: December 12 2013.)
Mooney M (2007) Newly qualified Irish nurses’ interpretation of their preparation and experiences of registration. Journal of Clinical Nursing. 16, 9, 1610-1617. Morgan A, Mattison J, Stephens M, Medows S (2012) Implementing structured preceptorship in an acute hospital. Nursing Standard. 26, 28, 35-39. National Nursing Research Unit (2009) Providing Preceptorship for Newly Qualified Nurses: What are
Welsh Assembly Government (2009) Post Registration Career Framework for Nurses in Wales. Welsh Assembly Government, Cardiff. Whitehead B, Holmes D (2011) Are newly qualified nurses prepared for practice? Nursing Times. 107, 19-20, 20-23. Willis Commission on Nursing Education (2012) Quality with Compassion: The Future of Nursing Education. Report of the Willis Commission on Nursing Education. Royal College of Nursing, London.
© NURSING STANDARD / RCN PUBLISHING
Downloaded from RCNi.com by ${individualUser.displayName} on Dec 03, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Provision of training and support for newly qualified nurses Jones A et al (2014) Provision of training and support for newly qualified nurses. Nursing Standard. 28, 19, 44-50. Date of submission: August 8 2013; date of acceptance: October 7 2013.
Abstract Aim To evaluate nurses’ and ward managers’ experience of the Nurse Foundation Programme (NFP), with a view to improving future programmes. The NFP was introduced in 2008 to provide newly qualified nurses with standardised training and support during their first year post-training in Cardiff and Vale University Health Board. Method Anonymous evaluation forms were analysed and interviews with nurses and ward managers were undertaken. Evaluation form data were descriptively analysed, and interviews and free text comments were thematically analysed. Findings The NFP was highly valued by attendees, offering timely knowledge and support for newly qualified nurses. Ward managers reported that the NFP made it easier to release time for newly qualified nurses to participate in training, while helping with skill mix decisions on the ward. Conclusion The centrally planned and coordinated NFP was positively evaluated and led to a standardised approach to training and support for newly qualified nurses.
Authors Aled Jones Senior lecturer, School of Healthcare Sciences, Cardiff University. Judith Benbow Lecturer and associate director of international and engagement, School of Healthcare Sciences, Cardiff University. Rachel Gidman Senior manager for nurse education, Cardiff and Vale University Health Board. Correspondence to: [email protected]
Keywords Newly qualified nurses, preceptorship, service evaluation, training, workforce evaluation
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above. 44 january 8 :: vol 28 no 19 :: 2014
IT IS ESTIMATED THAT more than half of the nursing workforce is newly qualified, therefore ensuring the smooth transition from student to qualified nurse should be a priority for nurse managers and the NHS (Whitehead and Holmes 2011). Health secretary Jeremy Hunt’s recommendation that nursing students in England work as healthcare assistants for one year before undertaking their training, focused debate on the commencement of nurses’ careers (Gillen 2013). The transformation from nursing student to registered nurse involves a change in status, role and responsibility, and this is seen as a period of uncertainty, stress and disorientation for newly qualified nurses. Kramer (1974) described how newly qualified graduate nurses experienced ‘reality shock’, characterised by the feeling that they were inadequately prepared for their new role. Equivalent experiences of newly qualified nurses are captured by Duchscher’s (2009) transition shock theory based on long-term research with nurses in Canada (Figure 1). Duchscher’s (2009) theory proposes that newly registered nurses undergo a process of physical, emotional, intellectual and socio-developmental adjustment that is motivated and mediated by changing roles, relationships, responsibilities and levels of knowledge in their personal and professional lives. Although Kramer’s (1974) and Duchscher’s (2009) work is based on the experiences of north American nurses, similar issues have been identified in studies from the UK, Australia and Ireland, with problems during transition being partly attributed to variable levels of support by employers during the initial post-qualification period (Mooney 2007, Higgins et al 2010). The transition from student to registered nurse involves a process of learning, adjustment and socialisation to the new workplace. It is important that the employer supports the newly qualified nurse through this process because early experiences in the workplace may be strong predictors of future work satisfaction, with negative early experiences potentially having a significant negative effect on future career development (Banks et al 2010, Jamieson et al 2012).
© NURSING STANDARD / RCN PUBLISHING
Downloaded from RCNi.com by ${individualUser.displayName} on Dec 03, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Preceptorship In recognition of the transition shock experienced by newly qualified nurses, healthcare organisations provide programmes of support for new staff members. For example, preceptorship programmes and online learning have been designed to assist new practitioners with the transition to registered practitioner (National Nursing Research Unit (NNRU) 2009, Jamieson et al 2012). The term preceptorship in the UK is associated with providing support for newly qualified nurses and other healthcare practitioners, whereas outside the UK, especially in North America, preceptorship is often associated with support given to nursing students. Preceptorship is defined by the Nursing and Midwifery Council (NMC) (2006) as a process that provides support and guidance, enabling new registrants to make the transition from student
to accountable practitioner. The NMC (2006) recommends that all new registrants be offered a period of preceptorship when starting employment. This is also recommended by the Department of Health (DH) (2010) in England, and the Welsh Assembly Government (2009), which advocates that nurses in Wales ‘be afforded protected learning time in their first year of practice and the support of a preceptor’. However, a review of preceptorship undertaken by the NNRU (2009) concluded that preceptorship programmes were not universally available. Furthermore, periods of preceptorship ranged from one month to more than six months, and satisfaction was greater with preceptorship of four months or longer than with shorter periods. The review also concluded that few robust studies focusing on preceptorship existed in the UK or elsewhere.
FIGURE 1 Transition shock theory Relationships
Disorientation
Transition shock
Roles
Loss
Intellectual: Reality shock – theory/practice incongruencies and practice improprieties. Lack of knowledge of transition. Lack of awareness regarding graduate roles and responsibilities. Limited practice aspect/pattern recognition. Limited tacit/practical knowledge. Practice inconsistency/unpredictability. Limited decision making and clinical judgement capacity. Organisational naivety. Professional role-relations immaturity. Limited performance feedback.
Doubt
Emotional: Labile nature of emotions. Emotions variable in origin. Intense and overwhelming period. Extreme sensitivities. Seeking validation and reassurance. Look for familiar protective nurturing. Require positive reinforcement. Fears of failure or incompetence. Fears of disappointing family, friends and colleagues. Loss of control. Lack of support.
Confusion
Socio-developmental: Changing social structures. Role uncertainty and unfamiliarity. Inadequate and insufficient guidance and/or assistance. Professional culture naiveté. Intra-interdisciplinary relations. Intergenerational dynamics. Leadership and delegation skills lacking. Oppressively hierarchical work structure. Evolving self – separation from dependent role. Loss of known supports. Insufficient exposure to role models.
Responsibilities
Physical: Relentless and terminal physical, emotional and intellectual exhaustion. Energy consumed to conceal feelings and transition responses. Physical demands of acute care Unaccustomed to full shift presence or full-time shift rotation. Emotional extremes. Maladjustments to shift work. Sleeplessness – active dreaming. Poor nutrition and lack of exercise. Change to social habits and routines.
Knowledge (Duchscher 2009)
© NURSING STANDARD / RCN PUBLISHING
january 8 :: vol 28 no 19 :: 2014 45
Downloaded from RCNi.com by ${individualUser.displayName} on Dec 03, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science service evaluation Cardiff Nurse Foundation Programme Approximately 150 newly qualified nurses are recruited by the Cardiff and Vale University Health Board (UHB) in Wales each year when they graduate from pre-registration nursing courses. A review, undertaken in 2008, of support and training offered to newly qualified nurses across the UHB found significant variation in the type and duration of training offered by hospital wards and departments. For example, some wards delivered initial orientation and induction programmes for newly qualified nurses allied to mandatory and essential training provided by the UHB, such as medicines management or infusion pump training. Other areas had no orientation or induction programmes in place, offering mandatory training courses only for newly qualified nurses. In addition, several ward managers experienced difficulties booking and releasing staff to attend mandatory or essential training because these were arranged at relatively short notice. As a result of these factors, some nurses received little or no training and support when starting their first nursing posts. The relatively small numbers of newly qualified nurses undertaking induction training in many departments was also considered an inefficient use of time and resources, resulting in duplication of effort and the potential for variation in the content, delivery and outcome of training. Following the review, a centrally designed and co-ordinated approach to training and support of newly qualified nurses was mandated by senior nursing management. Consequently, the UHB’s learning, education and development department, and a group of professional and practice development nurses, designed the Nurse Foundation Programme (NFP), which offers orientation,
TABLE 1 Comparison between the previous training and support regimen and the Nurse Foundation Programme Previous training and support
Nurse Foundation Programme
Variable access to training and support offered to newly qualified nurses.
Training and support undertaken by all newly qualified nurses.
Variable content and outcomes of training offered.
Standardised content and outcomes of training.
Duplication of effort because training and support activities existed in isolation with no co-ordination.
Efficient use of resources, with two groups per year being trained and supported.
Mandatory training events arranged at short notice, resulting in ward managers experiencing difficulties with booking and releasing time for staff to attend.
Central booking system, with training events arranged at least three months in advance.
46 january 8 :: vol 28 no 19 :: 2014
induction, and training and support. The first NFP cohort began in October 2008, and two cohorts per year (in October and April) have participated in the NFP since that time; 577 newly qualified nurses have completed the programme to date. The NFP comprises 13 study days that span the nurse’s first year of employment. The content of the programme is based on mandatory requirements, as well as some basic and essential skills and knowledge that were not included, or only partially covered, during pre-registration nurse education. The study days cover topics such as infusion pump workshops, medicines safety and management, intravenous (IV) drug administration, mentorship, and documentation and legal issues. The study days are arranged in advance, providing ward managers and NFP attendees with sufficient opportunity to arrange time off work to attend. All nurses undertaking the NFP are allocated a nurse preceptor, an individual who helps support the learning and developmental needs of the newly qualified nurse during this period of adjustment. Details of the changes introduced by the NFP are shown in Table 1.
Ethics The project proposal to evaluate nurses and ward managers’ experience of the NFP was reviewed and deemed to be a service evaluation by the Cardiff and Vale UHB Research and Development Committee, therefore ethical approval was not required. The service evaluation project plan was reviewed by Cardiff University’s School of Nursing and Midwifery Studies Research Review and Ethics Screening Committee.
Aim The aim of the service evaluation was to: Describe interviewees’ assumptions, expectations and experiences of the programme. Present interviewees’ opinions about the structure and content of the programme. Use the outcomes of the evaluation to plan future programmes.
Method Since 2008, the NFP has been evaluated anonymously via an evaluation form designed by the NFP team. The form consists of a numerical rating scale indicating the usefulness of the programme, ranging from 0 (no use at all) to 10 (extremely useful). Free text boxes also appear on the evaluation form, asking for written feedback on the perceived usefulness or lack of usefulness of various programme elements. These data were
© NURSING STANDARD / RCN PUBLISHING
Downloaded from RCNi.com by ${individualUser.displayName} on Dec 03, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
accessed and collated from 212 evaluation forms. While data on the evaluation forms were available, it was decided to undertake a more detailed assessment on the fifth anniversary of the NFP’s inception. As a result, interviews were undertaken with attendees who had completed the course and with ward managers who arrange for newly qualified nurses to attend the NFP (Table 2). Interview participants received an information letter about the evaluation at least two days in advance of being recruited, which explained that data collected were to be held confidentially and the identities of participants were to be anonymised. To minimise any sense of coercion to participate, information and invitations to take part in the interviews were delivered in the following ways: NFP attendees – information sheets, posters and letters were displayed in clinical areas where nurses work who were attending or had completed the NFP. Interested individuals were directed to email or telephone to arrange a date and time for interview. Members of the NFP and/or learning, education and development department team were not involved in the direct recruitment of participants, minimising any sense of coercion or threats to the independence of the evaluation. All recruitment and interviewing was undertaken by two of the authors, (AJ and JB), from Cardiff University, who were commissioned to undertake the evaluation. Ward managers – invitations to participate in the evaluation were distributed to ward managers via hospital email. Times, dates and locations for the interviews were arranged with managers who indicated their willingness to participate. Interview schedules (which may be requested via email) were designed to ensure that any areas of common interest were discussed within, and where relevant, between the different interview groups. For example, interviewers were interested in whether similar views about the usefulness of the NFP were common to ward managers and NFP attendees, as well as different areas of clinical practice. Interviews lasted 45 minutes on average.
Data analysis
Following transcription of the interviews, content and thematic analysis of the interview data and free text comments on the evaluation form was undertaken by two members of the evaluation team (AJ and JB) who had no involvement with the day-to-day planning or running of the NFP. Although the authors were mindful of the aims of the study, any unanticipated themes that emerged
© NURSING STANDARD / RCN PUBLISHING
from the data analysis were also considered (le May and Holmes 2012). Descriptive quantitative analysis of routinely collected evaluation forms added comparative data.
Findings Evaluation forms
The NFP was evaluated positively by NFP attendees who had completed the evaluation form; mean usefulness score of 8 out of 10, with all cohorts averaging a usefulness score of at least 7.5 out of 10. Written comments in the free text boxes also demonstrated that newly qualified nurses valued the support provided by the NFP. Particularly beneficial was the opportunity to interact and share learning with others who were newly qualified during a ‘key year’, as described by one participant (Box 1). The NFP was also described by attendees as being well organised. Less positive comments related to late cancellations and changes to scheduled training sessions, although these incidents occurred mainly because of speakers
TABLE 2 Clinical areas and number of participants who took part in semi-structured interviews on fifth anniversary of the NFP Sample
Clinical area and number of participants
Nurse Foundation Programme attendees (2009-2012) (n=15)
Acute general medicine (n=5), mental health (n=3), paediatrics (n=2), surgery (n=5)
Ward managers (n=5)
Acute general medicine (n=2), mental health (n=1), paediatrics (n=1), surgery (n=1)
BOX 1 Examples of positive and negative comments in free text boxes Positive comments: Very useful. Enjoyable, NFP is really good. Very helpful. Excellent. Really good to see other newly qualified nurses going through same experiences. Great support, good to meet other newly qualified nurses. Valuable training for newly qualified nurses. Excellent lectures, more up-to-date than university. Very well planned, good content, informative. Great structure – good to know in advance to arrange shifts. Thank you for support and guidance in a key year. Negative comments: Useful, however, some things repeated from university. Some classes need to be more specialist for paediatric nurses. Mental health-specific days would help. No prior notice of speaker not turning up. Qualified nine months ago and would have liked this sooner.
january 8 :: vol 28 no 19 :: 2014 47
Downloaded from RCNi.com by ${individualUser.displayName} on Dec 03, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science service evaluation being unable to attend for a variety of reasons. One frequently raised issue was the need for more training sessions to be dedicated to newly qualified mental health and children’s nurses. Recommendations by participants included scheduling the IV drug administration training sessions earlier in the programme, being awarded a certificate to signify completion of the NFP, including IV cannulation, and delivering content via an online platform.
Semi-structured interviews
The data collected during interviews were analysed and the following themes were identified: Support for newly qualified nurses and ward managers. Programme organisation. Recommended changes to the NFP. Support for newly qualified nurses and ward managers Echoing some of the comments in the free text boxes, several newly qualified nurses described how supportive the programme was during transition from student to newly qualified nurse. In particular, the 13 study days afforded an opportunity for nurses to share and learn from their colleagues’ experiences in a supportive and non-threatening environment. One interviewee commented that: ‘everyone talks about how they feel which gives me confidence’ (NFP attendee 7). Even though a training session would provide instruction on a technical skill, such as placement of a nasogastric tube, the discussion and support would often extend beyond the particular procedure: ‘So, the study days not only help me to be confident with doing sometimes difficult things like IVs or NG tubes, but it also really helps to see that I’m not the only one struggling or asking stupid questions about these things. When we get into discussions around our tables everything gets talked about, like off-duty problems, hassles with ordering uniforms as well as the stuff they are trying to teach us’ (NFP attendee 12). Even though the NFP offered support, the impact of being a newly qualified nurse was also apparent: ‘The programme does help with coming to terms with the change in role, but nothing can really prepare you for the responsibility you feel’ (NFP attendee 3). ‘It helps that I’m on the programme and that the ward is supportive, but I still sometimes panic at the thought of being in charge of patients’ (NFP attendee 9). 48 january 8 :: vol 28 no 19 :: 2014
Ward managers also discussed how they were supported by the NFP: ‘It’s less work for me now compared to trying to book different courses and balance the off-duty’ (Ward manager 2). ‘Since having the NFP it’s easier to plan the skill mix. I now know where the newbie [new] nurses are in terms of having had certain training at certain times. Before it was a lot more haphazard with things being cancelled at short notice’ (Ward manager 3). ‘Yes it definitely helps me plan shifts when I know that say three months in they will be up to speed with [infusion] pump training’ (Ward manager 4). Programme organisation Ward managers also appreciated the support of having a centralised and co-ordinated approach to organising the NFP: ‘Used to be tough getting them on to mandatory training, never enough notice given, but now I know well in advance when the study days are going to be and they [nurses] will come back knowing what they need to’ (Ward manager 3). ‘It’s good to know when we have someone new starting that there’s one less thing to organise like meds [medicines] management or updating mandatory training… I’m able to roster much better also and it gives the new band 5s a bit of protection time wise. It’s good that it doesn’t matter where you are in the UHB you know that all the new band 5s have had more or less the same initial training’ (Ward manager 1). The attendees described having study days organised in advance as a ‘godsend’ (NFP attendee 9) and ‘just what is needed when you are new ‘cos you don’t want to apply and organise study leave straight away’ (NFP attendee 1). The NFP is seen as offering equal opportunity to participate since it ‘doesn’t matter where you are in the UHB’ (Ward manager 1) everyone is entitled to attend regardless of ability to gain approval for study leave funding and/or time. Recommended changes to the Nurse Foundation Programme Interviews and comments in free text boxes would often indicate areas where the NFP could be further improved (Box 2). All suggestions have been taken into consideration by the NFP team. For example, suggestions for more specific content for different fields of nursing and earlier coverage of medicines management and IV drug
© NURSING STANDARD / RCN PUBLISHING
Downloaded from RCNi.com by ${individualUser.displayName} on Dec 03, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
administration have led to changes in the NFP timetable. Providing more information about career development, and education and training opportunities following completion of the NFP, was included in the programme for the October 2013 cohort. Increased use of online learning content requires further exploration to assess feasibility in terms of content development costs and access to personal computers in the workplace. Further steps are planned for closer working between the end of third-year training at the local university and the NFP, for example to ensure that recent content from the undergraduate programme is not repeated unnecessarily. However, not all newly qualified nurses recruited into the UHB are trained locally, although most are, which means closer working may only improve the programme for some participants.
Discussion The results of the evaluation are limited because not all NFP attendees completed the evaluation forms (n=212) and a relatively small number of interviews were undertaken in one area of the UK only. This may have led to bias because the forms may have been completed only by those attendees who were generally satisfied with the course. However, this seems unlikely because the forms were anonymous to encourage candid feedback, and negative comments and ratings appear in the forms that were made available to the evaluation team. Although the NFP was initially conceived as a means of co-ordinating and centralising the training offered to newly qualified nurses, it is clear that nurses benefit from the support of colleagues undertaking the NFP. This positive unintended consequence seems to occur naturally from gathering a group of nurses together who are undergoing a period of profound change, or reality or transition shock. Similar findings were discussed by Banks et al’s (2010) evaluation of the Flying Start NHS programme in Scotland, who reported that ‘supervisor support to newly qualified nurses is crucial during this period’. The face-to-face contact and support opportunities afforded by the NFP were of benefit to attendees, and to the organisation, since newly qualified nurses who feel supported are more likely to adjust better to the demands of their role (Lauder et al 2008, DH 2010). The co-ordinated and standardised approach to training was appreciated by ward managers who viewed the NFP structure as less ad hoc than before. Morgan et al (2012) found that more, rather than less, structure is preferable for such programmes. The practical implications of the NFP structure, namely that ward managers have a better
© NURSING STANDARD / RCN PUBLISHING
BOX 2 Areas for improvement in the Nurse Foundation Programme More specific content for children’s and mental health nursing. Medicines management, infusion pump training and intravenous drug administration content to be delivered earlier in the programme. Increased use of online learning. Increased links with nurse training in local higher education institution, particularly near the completion of training. More information about career development, and training and education opportunities beyond the programme.
understanding of the skill set of newly qualified nurses, makes decisions about patient allocation and skill mix easier to manage. For example, ward managers now know that newly qualified nurses are competent in IV drug management and administration within six months of qualifying, whereas before the NFP those nurses may or may not have attended the relevant study day within the first six, or even 12 months. The NFP means that ward managers know which newly qualified nurses have the relevant skill set or competencies and at what point during their first year following registration. This is a consequence that has not been discussed elsewhere in the literature in relation to newly qualified nursing programmes. Planning the programme has solved the problem of time release experienced elsewhere with similar programmes (Lauder et al 2008). However, some occurrences of non-attendance remain because of the need to cover shifts, although this is an exception. The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) recommended that nurses demonstrate up to date learning on an annual basis, consisting of documented evidence of recognised training and wider relevant learning. The NFP goes some way to meeting this requirement because it provides documented learning opportunities in a supportive environment. Further recommendations, such as the demonstration to commitment, compassion and caring evidenced by patient and family feedback, is not explicitly present in the NFP and is an area for future consideration and inclusion. Suggested areas for improvement that were raised via interviews and written feedback have been implemented, or are in the process of being realised. More field-specific training is now being provided for children’s and mental health nurses, while the joining up of the NFP with future learning opportunities, such as leadership and preparing to manage courses, is soon to be implemented by giving newly qualified nurses a clear understanding of the progressive learning on offer via the learning, education and development january 8 :: vol 28 no 19 :: 2014 49
Downloaded from RCNi.com by ${individualUser.displayName} on Dec 03, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science service evaluation department. This final point evokes a pertinent discussion within the Willis Commission on Nursing Education (2012) report, which described nurses’ competence and confidence as ‘part of a journey with various landmark stations, and not a fixed end point’. Thus, while the NFP provides those nurses at the threshold of their careers with a firm grounding, there is also the recognition that within the context of their careers the availability of a series of learning opportunities, rather than a single programme of learning, is required.
Conclusion Difficulties associated with the transition from nursing student to newly qualified nurse suggest that it is important to focus on the way in which practitioners commence their nursing careers. Although transition is a challenging time for nurses, the evaluation of the NFP demonstrated that its centralised, co-ordinated and supportive nature is highly regarded by newly qualified nurses and ward managers. The programme is a work in progress
and suggested areas for improvement have and are being implemented. Although the benefits to the UHB were not directly measured or captured, there is a clear link between high-performing organisations and maintaining a workforce that considers itself supported and valued NS
IMPLICATIONS FOR PRACTICE A centrally planned and co-ordinated approach is important when supporting newly qualified nurses. Newly qualified nurses appreciate the support and learning opportunities provided by the Nurse Foundation Programme (NFP). Making the NFP obligatory provides an equal opportunity for training and support for all nurses, regardless of the clinical setting. A standardised programme means ward managers and others have an up-to-date understanding of the skill set of newly qualified nurses. Ward managers felt that the NFP made it easier to release time for newly qualified nurses to participate in training.
References Banks P, Kane H, Roxburgh M et al (2010) Evaluation of Flying Start NHS. Final Report. tinyurl.com/ kkmp93y (Last accessed: December 12 2013.) Department of Health (2010) Preceptorship Framework for Newly Registered Nurses, Midwives and Allied Health Professionals. The Stationery Office, London.
experiences and perceptions of the newly qualified nurse in the United Kingdom. Nurse Education Today. 30, 6, 499-508. Jamieson L, Harris L, Hall A (2012) Providing support for newly qualified practitioners in Scotland. Nursing Standard. 27, 2, 33-36.
Gillen S (2013) Ministers ‘take a slug’ at the RCN for slamming HCA plan as ‘stupid’. Nursing Standard. 27, 34, 6.
Kramer M (1974) Reality Shock. Why Nurses Leave Nursing. Mosby, St. Louis MO. Lauder W, Roxburgh M, Holland K et al (2008) Nursing and Midwifery in Scotland: Being Fit for Practice. The Report of the Evaluation of Fitness for Practice Pre-Registration Nursing and Midwifery Curricula Project. tinyurl.com/lvelzut (Last accessed: December 12 2013.)
Higgins G, Spencer RL, Kane R (2010) A systematic review of the
le May A, Holmes S (2012) Introduction to Nursing Research.
Duchscher JEB (2009) Transition shock: the initial stage of role adaptation for newly graduated registered nurses. Journal of Advanced Nursing. 65, 5, 1103-1113.
50 january 8 :: vol 28 no 19 :: 2014
Developing Research Awareness. Hodder Arnold, London.
the Components of Success? King’s College London, London.
Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Executive Summary. The Stationery Office, London.
Nursing and Midwifery Council (2006) Preceptorship Guidelines. NMC Circular 21/2006. tinyurl. com/35go2r6 (Last accessed: December 12 2013.)
Mooney M (2007) Newly qualified Irish nurses’ interpretation of their preparation and experiences of registration. Journal of Clinical Nursing. 16, 9, 1610-1617. Morgan A, Mattison J, Stephens M, Medows S (2012) Implementing structured preceptorship in an acute hospital. Nursing Standard. 26, 28, 35-39. National Nursing Research Unit (2009) Providing Preceptorship for Newly Qualified Nurses: What are
Welsh Assembly Government (2009) Post Registration Career Framework for Nurses in Wales. Welsh Assembly Government, Cardiff. Whitehead B, Holmes D (2011) Are newly qualified nurses prepared for practice? Nursing Times. 107, 19-20, 20-23. Willis Commission on Nursing Education (2012) Quality with Compassion: The Future of Nursing Education. Report of the Willis Commission on Nursing Education. Royal College of Nursing, London.
© NURSING STANDARD / RCN PUBLISHING
Downloaded from RCNi.com by ${individualUser.displayName} on Dec 03, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
