New Graduate Nurses’ Transition to Practice During the COVID-19 Pandemic: Voices of Clinical Nurse Educators From the Front Lines

Abstract

Introduction

Although COVID-19 may no longer be a global public health emergency, it is imperative to continue to reflect on the lessons learned from it, especially from the front-line nurses and nurse educators, to ensure effective nursing workforce response to disasters and emergencies of all kinds. The COVID-19 pandemic has disproportionately affected the new graduate nurses (NGNs) by altering their transition to practice (TTP) experiences. Many studies have examined perceptions and voices of educators from nursing education programs and NGNs about their experiences of transitioning to practice during the pandemic. However, clinical nurse educators’ voices are lacking.

Method

This qualitative descriptive study explored clinical nurse educators’ perspectives on the differences in TTP before and during the pandemic.

Results

The preliminary results encompassed two themes No hands on and Used to interacting with mannequins that point to root causes of greater struggles NGNs who transitioned to practice during the pandemic faced compared to their pre-pandemic counterparts.

Conclusion

Safely maintaining clinical access to learners during public health emergencies will be imperative to ensure NGNs enter practice prepared to provide safe and high-quality care.

Although COVID-19 may no longer be a global public health emergency, it is imperative to continue to reflect on the lessons learned from it, especially from the front-line nurses and nurse educators, to ensure effective nursing workforce response to disasters and emergencies of all kinds (Evans, 2021). The COVID-19 pandemic has disproportionately affected the new graduate nurses (NGNs) (Lee et al., 2024; Martin et al., 2023; Riess et al., 2023) by altering their transition to practice (TTP) experiences (Feeg et al., 2022). There are several studies of NGNs’ TTP during the pandemic (Aukerman et al., 2022; Blanco et al., 2023; Bultas & L’Ecuyer, 2022; Djukic et al., 2023; Glynn et al., 2022; Lee et al., 2024; Martin et al., 2023; Overbaugh et al., 2022; Riess et al., 2023). However, clinical nurse educators’ perspectives are lacking (Powers et al., 2021). The researchers aimed to fill this knowledge gap by studying clinical educators who were able to compare NGNs before and during the pandemic, while NGNs themselves did not have a pre-pandemic view of the transition.

Existing Research on New Nurses’ Transition to Practice

The existing research on NGNs’ TTP and the COVID-19 pandemic largely highlights perspectives of NGNs. A national survey study in the United States of America (U.S.A.) of 2,664 NGNs found that transitioning during the pandemic was difficult for NGNs due to the increased use of simulation, lack of on-site clinical educational experiences, and mentoring both in academic and work settings (Feeg et al., 2022). Also, a multi-site study of 2,673 NGNs from Texas, who participated in the Vizient/AACN Nurse Residency Program, showed that NGNs during the pandemic compared to NGNs prior to the pandemic scored significantly lower (p < 0.05) on advocacy, patient safety, and commitment to nursing (Djukic et al., 2023). Several qualitative studies across the U.S.A. including South Dakota, Illinois, Missouri, Texas, Massachusetts, and Tennessee reported similar findings from NGNs who shared that they were not prepared to care for patients with COVID-19, had high levels of stress and anxiety, lacked hands-on experience, and felt unsafe and overwhelmed at work (Aukerman et al., 2022; Blanco et al., 2023; Bultas & L’Ecuyer, 2022; Djukic et al., 2023; Glynn et al., 2022; Martin et al., 2023; Overbaugh et al., 2022). Despite the reports of negative experiences, NGNs reported being able to grow personally and professionally with the support of colleagues and clinical educators.

In terms of nurse educator's perspectives in response to COVID-19, Riess et al. (2023) conducted a scoping review to identify educators’ challenges with teaching. Of the 34 studies they included in their review, none were with clinical educators in hospitals. Powers et al. (2021) studied views from the faculty teaching in nursing programs in North Carolina on NGNs’ TTP during the pandemic. The faculty reported increases in students’ absenteeism from didactic and clinical courses and significant decline (p < 0.05) in readiness to practice across several domains including clinical knowledge, technical skills, critical thinking, communication, professionalism, and management responsibilities.

Study Purpose

The purpose of this study was to elicit voices of clinical nurse educators, a key stakeholder group, who worked side by side with NGNs on the front lines in the middle of the pandemic. The research question was: What are your perceptions and experiences with NGNs as they transitioned to practice pre-COVID-19 pandemic versus during the COVID-19 pandemic?

Method

The researchers obtained approval from the institutional committee for the protection of human subjects to conduct the study. The study used a qualitative descriptive design (Sandelowski, 2000).

Participants and Setting

The researchers used purposive sampling to recruit hospital-based nurse educators and NGNs residency program coordinators from a large health system in Texas. Specifically, to recruit participants, information about the study was shared during in-person meetings attended by the hospital-based clinical educators and NGN residency program coordinators. The health system participates in the Vizient/American Association of Colleges of Nursing Nurse Residency Program, which includes a 1-year residency curriculum with monthly seminar sessions on topics such as critical thinking, decision making, clinical judgment, clinical leadership and communication, and evidence-based practice, and dedicated advisor support (Vizient, 2024). The study was open to clinical educators and NGN residency program coordinators who worked both prior to and during the COVID-19 pandemic.

Data Collection

The researchers conducted one focus group and three individual interviews using a virtual interview platform with a semi-structured interview questionnaire from January to May, 2023. The researchers originally intended to conduct focus groups, but were faced with scheduling challenges in coordinating nurse educators’ availability. Therefore, the researchers shifted to individual virtual interviews to enable further data collection. There were three participants in the focus group and additional three participants in the individual interviews. The focus group and interviews were approximately 25 min in length and were recorded and transcribed verbatim.

Data Analysis

Author, DC, listened to the recordings and read the transcripts in their entirety to gain an overall appreciation and understanding of the data. The data were analyzed using qualitative content analysis, whereby the data were coded and organized into related clusters and themes using an iterative process (Miles et al., 2020). A second author, MD, reviewed the data and codes and engaged in a discussion with Author DC until there was consensus on the identified themes. The themes were shared with all authors for input and feedback. Due to the small sample size for this pilot study, claiming data saturation is not appropriate. However, the themes that emerged had strong agreement from most study participants and add to the available literature on NGNs TTP during COVID-19.

Results

Analysis of the data identified two themes related to differences between NGNs entering the workforce pre-pandemic and during the pandemic: (a) “No hands on,” and (b) “Used to interacting with mannequins.” These two themes, resulting from participants’ direct quotes, best describe the differences identified by the residency coordinators and nurse educations in our study.

Theme 1: No Hands On

The theme one speaks to lack of proficiency with basic clinical nursing skills. These were skills in which hospital-based educators expected all NGNs to have minimal proficiency prior to completing a nursing program. For example, participant 1 described the lack of clinical experiences as, “Oh, man! No hands on. Absolutely no hands on. Oh, it was evident, too. You can tell who might have attended maybe one clinical versus a person who had clinicals and simulation at school, and then that person who had nothing.” Another (Participant 2) stated, “It's like simple stuff that is really not there. The foundational nursing.” Hospital-based educators attributed this lack of clinical skill proficiency to hospitals limiting access to student nurses, “The nurses that came to us, they were missing much of their clinical hours from nursing school because the hospitals weren't allowing students to come in” (Participant 3). Participant 1 also stated, “ … Overall that lack of clinical exposure was a big barrier … them not coming, nurses not coming to the clinical setting was huge …” Participant 4 summed up her perspective on NGNs’ lack of skills by stating, “Just skill set in general. I mean, I had a nurse that did not know how to empty a Foley … She just did not know how to empty a Foley. She didn't know how to spike a bag. Just the simple skills that are taught in school, she just lacked it.”

NGNs lack of skills pushed residency programs to implement new strategies to address the gap. Participant 5 recounted a strategy their hospital implemented, “We'd also have skills classes after seminar. We would do different skills and we would, form my med/surg nurses, we'd start them all for about two to three weeks as PCAs (patient care associate).” This participant stated that pre-pandemic they would pair NGNs with a PCA for about 1–2 days. Participant 4 stated, “… post-pandemic, I would meet with my new nurses once a week for one-on-ones, whereas before it was more like monthly check-ins…” A new strategy that was implemented, due to the unique nature of the pandemic itself, was the creation of a death and dying bereavement workshop, “I created a death and dying bereavement workshop… From that, we did like a simulation and are now developing a virtual reality [simulation] on how to hone in on those communication skills, those soft skills, … what to say and what to do during the dying process” (Participant 2).

Theme 2: Used to Interacting with Mannequins

The theme two, represented the idea that NGNs entering the workforce during the pandemic, had significant deficiencies with communication, in-person interactions, and fears and anxiety about working in the clinical setting. Participant 5 described it this way, “They didn't know how to talk to patients. They were just used to interacting with mannequins and not somebody that was going to talk back to them. So, they had a lot of fear of that.” Participant 6 noted more specifically how their lack of physical interaction with colleagues in the clinical setting as students impacted their ability to perform in the clinical setting during their residency program, “We had a lot of individuals who were scared of MDs. Scared of calling physicians, scared of SBARs; and even though that's a normal thing to be afraid of, I don't think it was just, ‘I'm afraid of it because I have to talk to a doctor.’ It was more like, ‘I'm afraid of it because I have not seen this done. I have not watched someone do this …” Participant 4 described this behavior in the context of a practice gap, “ … they would try to get other people to talk to the doctors for them… whereas before [the pandemic], I felt like more of them were like, ‘Ok, I don’t want to do this but I’m going to.’”

Participants attributed the lack of working with real patients as contributing to increased fears and anxiety in the clinical setting, “… I felt that a lot of the nurses came in still thinking they were students, even thought they were licensed. It's like they didn’t feel comfortable enough to act like they were nurses” (Participant 3). Participant 5 shared their perspective this way, “We saw that, even just going into a patient room by themselves, they had a lot of fear.” Another stated, “During the pandemic, it was more than confidence. It was just communication skills were lacking. They did not know how to talk to patients.”

Discussion

The study added evidence on the impact of the COVID-19 pandemic on NGNs TTP from clinical educators’ perspective. Their perspectives are significant because they are responsible for ensuring that new nurses who recently completed their pre-licensure nursing programs are safe to transition to actual clinical practice. Two themes comprised the results: (a) “No hands on,” and (b) “Used to interacting with mannequins.” The results are similar to what research focusing on the NGNs’ perspectives has found (Aukerman et al., 2022; Blanco et al., 2023; Bultas & L’Ecuyer, 2022; Djukic et al., 2023; Feeg et al., 2022; Glynn et al., 2022), clinical educators’ from our study found NGNs struggled with variety of basic nursing skills and interacting with live patients and physicians. However, alike Powers et al. (2021) reported, the struggles common for all NGNs were more pronounced in the NGNs who transitioned during the pandemic. The educators from this study also attributed the more pronounced lack of confidence and clinical skills to lack of clinical experiences with real patients and providers in clinical settings, which in turn prolonged the time needed to orient and transition NGNs who were impacted by the pandemic into independent practice. Lee et al. (2024) highlighted the need to further study social interactions between nurses and patients in clinical settings during crisis, especially when social interactions are limited due to infection prevention concerns.

Limitations

Limitations of this study include a small number of interviewees from sites that participated in the Vizient/AACN Nurse Residency Program (Vizient, 2024). The study was conducted in one large health system in Texas. Clinical educators from smaller or rural health systems without formal residency programs may have had different experiences. Future research must gather perspectives from a variety of stakeholders involved in NGNs TTP to inform the development of effective TTP strategies in surge situations, like pandemics.

Implications for Practice

The implications of the study for clinical educators’ practice are limited due to the small sample and a single study site. However, the study's results suggest that keeping nursing students away from clinical practice settings during the pandemic has hampered their basic nursing skills and abilities beyond what hospital-based clinical educators have observed in pre-pandemic NGN cohorts. In the future, when natural or human-induced disasters disrupt clinical access for nursing students for long time periods, clinical nurse educators can anticipate and plan for prolonged onboarding times and increased workload to transition NGNs to independent practice. In particular, NGNs whose education is heavily augmented with simulations and virtual technologies may need additional support in communicating with real-life patients and providers.

Conclusion

The data from clinical educators reinforced the importance of hands-on clinical experience in the actual practice settings for optimal development of basic and necessary nursing skills. While disaster preparedness curriculum for didactic and simulation education is available (Evans, 2021), research and recommendations on effective ways to maintain access to clinical learning settings during emergencies is needed. Finding safe ways to maintain clinical access to learners during public health emergencies will be imperative to ensure NGNs can enter the workforce prepared to provide safe and high-quality care.

Human Subject Statement

In this study, we analyzed previously collected data and the study received exempt status from the UTHealth Houston Committee for the Protection of Human Subjects.