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Bridging the Preparation-Practice Gap, Volume II

Best Practices for Accelerating Practice Readiness of Nursing Students

Topics: Orientation and Onboarding, Recruitment and Retention, Workforce, Mentoring and Coaching, Leadership, Clinical Skills, Skill Development

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Frontline nursing leaders are increasingly voicing concern about the practice readiness of new graduate nurses at the very same time hospitals and health systems are increasingly relying on such inexperienced staff.


By reading this study, members can:

  • Implement 11 best practices for targeting clinical rotations, elevating the quality of clinical instruction, ensuring exceptional student experiences
  • Take steps, in collaboration with local nursing schools, to ensure that nursing students are better prepared for practicing in the complex acute care environment

Executive Summary

Polarized Viewpoints on Practice Readiness

As the health care sector increasingly turns to inexperienced staff, hospital-based nursing leaders seem to be increasingly questioning new graduates’ practice readiness, a perspective that most academic leaders do not seem to share. According to recent Nursing Executive Center research, nearly 90 percent of academic leaders believe their new graduate nurses are fully prepared to provide safe and effective care, compared to only ten percent of hospital and health system nurse executives. Fortunately, these wide-ranging perceptions do not pose an insurmountable barrier to bridging what has come to be known as the preparation-practice gap. In the course of the Nursing Executive Center’s research, nearly all nursing leaders—nursing school deans, hospital and health system nurse executives, frontline managers and so forth—agreed that while even the best prepared new graduates will always have much to learn, more must be done to prepare nursing students for practicing in today’s complex care environment.

A Promising Opportunity for Collaboration

To better understand new graduate nurses’ specific improvement needs, the Nursing Executive Center surveyed over 53,000 frontline nurse leaders, at the direction of member executives. Both chief nursing officers and vice presidents of patient care services uniformly expressed that the closer proximity of nurse managers, educators, and charge nurses to the front line places them in a better position to accurately assess their new graduates’ performance.

Frontline nurse leaders were asked to rate their new graduate nurses’ proficiency on 36 key competencies. Perhaps not too surprising, the 12 competencies falling into the bottom third overwhelmingly involve skills—such as taking initiative, managing multiple responsibilities, and delegation—that are more readily honed in a clinical setting than a classroom. More surprising, Center research suggests that there is substantial untapped opportunity for hospitals to work with local nursing schools to develop these lowest ranked competencies during student clinical rotations. In large part because fully developing such competencies in an academic setting can be challenging, the lion’s share of hospitals have largely waited to address them until after a new graduate has been hired and placed on a unit. Best practice institutions, however, are now complementing these post-hire efforts with the types of collaborative, pre-hire initiatives outlined on the facing page to ensure new graduates are “practice ready” as early in their careers as possible.

Targeted Clinical Rotations

In light of the limited number of hours students spend in clinical settings during the course of their academic careers, ensuring that clinical rotations simultaneously provide a rich learning environment and realistic experience is critically important. Unfortunately, the current student rotational model all too often fails to prepare students for the demands of hospital practice. Dramatic improvement, however, does not necessarily require wholesale overhaul of existing rotations. Working with their local nursing schools, a growing number of hospitals and health systems are significantly enhancing new graduate preparation by implementing a handful of practices which prioritize select skills during rotations, create rich opportunities for repetitive practice on select skills, promote more tailored learning experiences, and re-structure rotations to more closely mirror the demands of a full nurse workload.

Expert Clinical Instruction

Regardless of structure or setting, at the heart of every educational experience is the skill of the educator.

Unfortunately, serving as an effective clinical teacher for student nurses seems to require an ever-increasing amount of knowledge and skill. In addition to keeping abreast of current evidence-based practice, clinical instructors now teach in multiple settings and thus must also learn unique, institution-specific knowledge. Perhaps even more troubling, only about one third of nurse preceptors report feeling able to effectively meet key teaching objectives. Recognizing these concerns, progressive institutions are striving to enhance student clinical rotations by taking concrete steps to elevate the quality of clinical instruction. More specifically, the Center recommends five best practices which collectively support both clinical instructors and preceptors in their teaching roles, foster the continued development of teaching techniques, and leverage home-based instructors with deeper organizational knowledge.

Exceptional Student Experiences

To truly optimize pre-hire efforts to narrow the preparation-practice gap, hospitals and health systems must strike a thoughtful balance between the depth and reach of initiatives they choose to pursue. Put another way, most institutions cannot afford to do everything for every nursing student. The majority of practices profiled in this report tend to prioritize the importance of reach—of positively impacting the lion’s share of nursing students participating in clinical rotations at a facility. The Center strongly recommends complimenting such practices with at least one of three profiled initiatives intended to profoundly impact a select number of students, provided there is high degree of likelihood that participating students will become future hires at your institution. Indeed, for organizations able to effectively channel future hires into such exceptional experiences, these admittedly resource-intensive initiatives are among the most likely to deliver an outsized return.

In total, the practices presented in this report suggest a more collaborative approach for bridging the gap between nursing preparation and practice. This research focuses entirely on strategies for enhancing preparation before students graduate from nursing school. Each practice has merit as a stand-alone initiative, but for most institutions, a comprehensive approach spanning all three strategies discussed here, as well as post-hire initiatives, will be required to instill full confidence in the practice-readiness of their new graduate nurses.

Assessing the Divide Between Nursing Preparation and Practice

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