Closing the Experience Complexity Gap for Novice Nurses

Since 2000, the U.S. has seen a 45% increase in nurses ages 23 to 35. At the same time, the number of experienced nurses is decreasing as the baby boomer generation enters retirement.

In July, Carol Boston-Fleischhauer, J.D., M.S., B.S.N., managing director and chief nursing officer of research at The Advisory Board Company, presented a webinar providing suggestions for navigating the increase in novice nurses within the workforce.

She also explained how the decrease in staff experience was heightened by an increase in the complexity of needs for hospitalized patients. “We’re not facing a shortage of people,” Boston-Fleischhauer said. “We are facing a shortage of experience.”

Increases in technology, patient expectations, and variety of necessary skills have caused an increase in the amount of time for a nurse to reach the level of competent compared to prior generations.

Dr. Patricia Benner’s novice to expert model, which Boston-Fleischhauer cited as a measure of a nurse’s experience level, includes five stages of clinical competence. The model is based on the premise that skills take repetition in similar situations with variables added over time to develop clinical competence.

“Unfortunately, because of the high complexity and variability in today's inpatient practice environment, novice nurses are being asked to take care of different types of patients with many different needs early in their career progression,” Boston-Fleischhauer said.

“Early mastery of any key skill becomes harder for them, slowing their progression to competent. This is what's exacerbating today’s challenging situation.”

Boston-Fleischhauer presented several best practice suggestions organizations may use to help new hires achieve success in a timely manner.

Teach novice nurses more effectively

While organizations aim to arm new staff with as much information as possible, many have added numerous education investments in recent years, including nurse residency programs, online learning modules, mentorship cohorts and simulation lab trainings.

“These are great investments,” Boston-Fleischhauer said. “And they are necessary to not only support your novice nurse, but to safeguard patient care. However, the unintended consequence is that we've added so many programs and trainings early in our novice nurses’ experience with us that they are reporting feeling overwhelmed and saturated.”

Some programs may also contain redundancies, conflicting information when presented multiple ways, and unintentional gaps. This results in nurses struggling to master essential skills in the transition from academia to patient care. Boston-Fleischhauer encourages organizations to look at their resources already in place and consider how to leverage them differently.

In 2013, Dartmouth-Hitchcock Medical Center in New Hampshire brought on a new director of education to address reports of overwhelmed novice nurses in the first weeks of training. The new program focused on first teaching the skills that key stakeholders deemed essential.

To accomplish this, Dartmouth staff narrowed their list of core competencies, prioritizing each skill so education was as progressive as possible, and designated where they would be taught (organization-wide, unit-based, or through ongoing education later in the year) to eliminate gaps and redundancies.

Better leverage existing experience: Starting preceptors on the right path

With the decrease in the average age of the nursing population, many preceptors are close in age with their trainees, presenting issues with their knowledge on complexity of care, evaluating competencies, and refining soft skills such as patient communication. Also, there are often variations in teaching style.

“Preceptors typically teach things the way they were taught and, unfortunately, that's not always the right way. A recent study found that nearly 25% of new nurses reported clinical preceptors actually contradicting organizational best practices and protocols during their early rotations; which obviously results in novice nurses learning substandard practices or mastering procedures or techniques inappropriately.”

The Hospital for Sick Children in Toronto, Ontario, redesigned its preceptor program to address these issues through a three-step process.

1. Prepare preceptors to be effective teachers. Before teaching their first class, all staff intending to teach their colleagues attended a four-hour workshop. Here, they focused on foundational skills and teaching techniques through a mixed-method approach employing role-play, debriefing and reflection. Emphasis was placed on teaching critical thinking skills.
2. Strengthen teaching skills with ongoing support. After teaching their first class, preceptors and educators attended a second, advanced skill-building workshop focused on self-assessment, time management, giving feedback and more.
3. Provide preceptors with actionable feedback. While most organizations host check-ins with preceptors regarding learning progress, emphasis in this program was placed on feedback from unit educators to help preceptors improve.

After initiating this program with 660 preceptors, the hospital saw a 4.64% increase in preceptor satisfaction. The Advisory Board Company prepared a Red Flag Checklist to assess the effectiveness of individual organization’s preceptor programs.