Casey Fink Journal Nursing Ed Readiness Article 6z6in

Readiness for Practice: The Senior Practicum Experience Kathy Casey, MSN, RN; Regina Fink, PhD, RN, FAAN, AOCN; Cathy Jaynes, PhD, RN; Linda Campbell, PhD, RN, CNS; Paul Cook, PhD; and Vicki Wilson, PhD, RN

ABSTRACT Nursing students must be prepared to enter the practice environment ready to competently care for patients. The purpose of this study was to examine factors hypothesized to influence senior nursing students’ perceptions of readiness for practice and to determine their level of comfort performing skills independently. This study also validates an investigator-developed instrument, the CaseyFink Readiness for Practice Survey. Factor loading indicated four components tested by subscales in the survey: clinical problem solving, learning techniques, professional identity, and trials and tribulations. The greatest challenges reported by students were managing multiple patient care assignments, communicating with physicians, and caring for dying patients. Clinical competency, role development, and career planning were areas in which students desired more assistance during their senior practicum course. Most survey respondents voiced confidence in their ability to problem solve and felt ready to assume the professional nursing role.

Received: March 20, 2011 Accepted: June 29, 2011 Posted Online: August 17, 2011 Ms. Casey is Adjunct Faculty, Dr. Fink is Adjunct Faculty, and Dr. Cook is Assistant Professor, University of Colorado Anschutz Medical Campus, College of Nursing, Aurora, Dr. Jaynes is Denver Campus Chair, Department of Nursing, University of Phoenix, Dr. Campbell is Associate Professor, Loretto Heights School of Nursing, Rueckert-Hartman College of Health Professions, Regis University, Denver, and Dr. Wilson is Professor, School of Nursing, University of Northern Colorado, Greeley, Colorado. Dr. Fink is also Research Nurse Scientist, University of Colorado Hospital, Aurora, Colorado. The authors have no financial or proprietary interest in the materials presented herein. Address correspondence to Kathy Casey, MSN, RN, Adjunct Faculty, University of Colorado College of Nursing, Campus Box C288, 13120 East 19th Avenue, Aurora, CO 80045; e-mail: [email protected]. doi:10.3928/01484834-20110817-03

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reparing nursing students to practice safely, effectively, and comionately in today’s rapidly changing health care setting is a challenge. New graduates enter the work force and find they have neither the practice expertise nor the confidence to navigate what has become a highly dynamic and intense clinical environment burdened by escalating levels of patient acuity and nursing workload (Duchscher, 2008). To better understand the practice readiness of graduate nurses, it is important to examine senior nursing students’ perceptions of their readiness for practice. BACKGROUND

The transition from an educational setting to the practice setting is widely recognized as a period of stress, role adjustment, and reality shock (Casey, Fink, Krugman, & Probst, 2004; Fink, Krugman, Casey, & Goode, 2008; Kramer, 1974). Graduate nurses have stated that they want additional clinical time, more technical skills, a broader range of real-life experiences, and more practice communicating with physicians during their educational program (Chappy, Jambunathan, & Mamocha, 2010). They have reported their nursing education program did not adequately provide them with pharmacology and pathophysiology content, leadership and management skills, electronic health record management, delegation skills, the ability to manage multiple patient care assignments, or recognize changes in patient condition (Berkow, Virkstis, Stewart, & Conway, 2008; Burns & Poster, 2008; Candela & Bowles, 2008; Li & Kenward, 2008). Difficulty transitioning into practice often forces graduate nurses out of the profession. Recent studies indicate 30% to 60% of graduate nurses change jobs or leave nursing altogether during their first year of practice. Feeling inadequately prepared for the pace of acute care, the challenge of high-acuity patients and disempowering, understaffed work environments are cited as reasons they leave the profession (Beecroft, Kunzman, Taylor, Devennis, & Guzek, 2004; Candela & Bowles, 2008; Kovner et al., 2007). Graduate nurse residency programs have been implemented to help facilitate the transition from nursing school into a range of practice environments, foster better paCopyright © SLACK Incorporated

CASEY ET AL.

tient outcomes, retain new graduates, and improve professional satisfaction (Goode & Williams, 2004; Goode, Lynn, Krsek, Bednash, & Janetti, 2009; Krugman et al., 2006; NCSBN, 2009). It is expected that most skills and competencies needed for entry into practice be acquired within the educational program the graduate nurse attended (Hickey, 2009). Nurse educators are pressured to improve this documented practice-education gap. Benner, Sutphen, Leonard, and Day (2010) have called for a “radical transformation in how nurses are educated, saying that profound changes in nursing practice call for equally profound changes in the education of nurses and preparation of nurses to teach nursing” (p. 16). They found that schools have lagged behind in adapting to these changes. Recently, the Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing (2010) noted that today’s nursing curriculum is dated and suggested that nurse educators improve the links between knowledge, clinical reasoning, and practice. READINESS FOR PRACTICE

Concerns about beginning nurses’ readiness for practice are not new. Accrediting bodies, such as the American Association of Colleges of Nursing (2008), provide specific outcomes that direct curricular priorities for undergraduate nursing programs to prepare students for the realities of today’s professional practice environments. There is evidence that an intensive, preceptorguided clinical experience for senior nursing students is effective in increasing the confidence of graduate nurses (Harrison & Stewart, 2007; Rush, Peel, & McCracken, 2004; Wieland, Altmiller, Dorr, & Wolf, 2007). Such a course is offered by the three baccalaureate nursing programs in this study. Offered in the semester prior to graduation, seniors are expected to synthesize and integrate their accumulated nursing knowledge, skills, and values in clinical practice settings where they are mentored by a nurse preceptor. The purpose of the course is to promote professional role development through leadership and management competencies in communication, conflict management, interdisciplinary collaboration, and use of information technology (Preheim, Fuller, Jaynes, Matthews, & Ward, 2009). Measuring the effectiveness of a senior practicum course is an essential step in improving the transition experience of graduate nurses. Previous studies related to preparation for practice have focused on students’ from their entire educational experience. Understanding students’ perceptions of readiness and preparedness for the professional nursing role is important and may provide insight into how the senior practicum develops students’ readiness for practice. PURPOSE OF THE STUDY

The purpose of this study was to examine the perceptions of baccalaureate nursing students enrolled in a senior practicum clinical course using an investigator-developed instrument. The specific aims were to: ● Identify those skills and procedures senior nursing students found difficult to perform independently. Journal of Nursing Education • Vol. 50, No. 11, 2011

● Validate an investigator-developed instrument used to measure the student’s level of confidence and comfort experienced in providing care. ● Understand the perception of student readiness for the professional nursing role. ● Identify and correlate readiness with individual characteristics and reasons for entering the nursing profession.

METHOD Design

This descriptive study used both a quantitative and qualitative approach. Exempt approval from the institutional review board was obtained from the three participating institutions prior to study initiation. Students were recruited to voluntarily participate. An investigator-developed survey, the Casey-Fink Readiness for Practice Survey, was distributed by instructors on the last day of senior practicum class or by Zoomerang e-mail notification; survey completion implied consent. Survey responses were anonymous. The instrument takes approximately 15 minutes to complete. Sample

Data were gathered from a convenience sample of 429 senior baccalaureate nursing (BSN) students (80% response rate) at three nursing programs in a western state from October 2008 to December 2009. Instrument and Data Analysis

A of expert clinical faculty reviewed a pilot instrument developed in 2007 for content validity prior to this study. Items were designed to target specific skills and nursing activities that senior nursing students would be expected to perform prior to graduation from their nursing education program and analyze levels of perceived readiness in light of personal characteristics and experience factors that were believed by the to influence readiness. The Casey-Fink Readiness for Practice Survey consists of three sections. The first section asks for demographic data and information about the student’s senior practicum experience: total hours, clinical setting, preceptor, and course content information. The second section focuses on the student’s comfort with skill performance—both clinical and relational. First, using a list of 18 skills and procedures, students are asked to identify the top three skills they are uncomfortable performing independently. Students had the option of adding items not listed. Second, students are asked about their level of confidence in managing multiple patient assignments. Third, students are presented with a list of 20 items asking for a self-report about comfort/confidence in key practice skills using a Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree, and 4 = strongly agree). It was this comfort/confidence questionnaire that was used to identify domains of readiness offered during the senior practicum in the development of confidence in senior nursing students. An exploratory factor analysis of all items on the development sample (obtained by surveying 162 students at one BSN education program in Den647

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TABLE 1 Factor Loadings in Exploratory Factor Analysis Solution for Development Sample Clinical Problem-Solving Subscale

Learning Techniques Subscale

Professional Identity Subscale

Trials and Tribulations Subscale

I feel confident communicating with physicians.

0.574

–0.153

0.331

0.180

I feel comfortable communicating with patients and their families.

0.337

0.205

0.510

–0.294

Scale Item

I am comfortable delegating tasks to the nursing assistant.

0.336

0.508

0.112

–0.491

I have difficulty documenting care in the electronic medical record.

–0.291

0.226

–0.374

0.581

I have difficulty prioritizing patient care needs.

–0.311

0.144

–0.136

0.731

My clinical instructor provided about my readiness to assume an RN role.

0.317

–0.093

0.537

–0.049

I am confident in my ability to problem solve.

0.744

–0.022

0.318

–0.155

I feel overwhelmed by ethical issues in my patient care responsibilities.

–0.057

0.048

–0.126

0.604

I have difficulty recognizing a significant change in my patient’s condition.

–0.401

0.095

–0.243

0.405

I have had opportunities to practice skills and procedures more than once.

0.335

0.140

0.345

–0.411

I am comfortable asking for help.

0.393

–0.161

0.576

–0.241

I use current evidence to make clinical decisions.

0.637

0.156

0.219

–0.277

I am comfortable communicating and coordinating care with interdisciplinary team .

0.796

0.042

0.278

–0.328

Simulations have helped me feel prepared for clinical practice.

–0.010

0.600

0.162

0.274

Writing reflective journals/logs provided insights into my own clinical decision–making skills.

0.155

0.746

0.037

0.044

I feel comfortable knowing what to do for a dying patient.

0.561

0.290

0.058

–0.134

I feel comfortable taking action to solve problems.

0.732

0.188

0.460

–0.297

I feel confident identifying actual or potential safety risks to my patients.

0.652

0.145

0.444

–0.415

I am satisfied with choosing nursing as a career.

0.042

0.073

0.767

–0.133

I feel ready for the professional nursing role.

0.409

0.299

0.709

–0.184

Cronbach’s alpha for subscale

0.80

0.50

0.65

0.63

Note. Bolded factor loadings indicate which subscale each item was assigned to in the final solution.

ver, Colorado) was followed by a confirmatory factor analysis to revalidate the exploratory factor analysis findings in a second independent sample (267 BSN students recruited from three BSN programs in Colorado). Exploratory factor analysis was conducted using SPSS version 19 software, and confirmatory factor analysis was conducted using AMOS version 19 software. Cronbach’s alpha was 0.69 overall for the 20 items on comfort/confidence. The initial solution (the exploratory factor analysis) using the Kaiser criterion suggested up to eight factors, but the most interpretable solution was a four-factor set of correlated subscales: clinical problem solving, learning techniques, profes648

sional identity, and trials and tribulations (Table 1). The final solution ed for 48.2% of the variance across all survey items. Each subscale contained from two to seven items, which were assigned to subscales based on their factor loadings and theoretical considerations regarding which items seemed to tap similar constructs. Although the learning techniques subscale (related to the use of simulation and the use of reflective writing as part of the nurse’s training experiences) included only two items, these two items loaded together on a single factor and appeared to provide valid data. All items on the other three subscales related to aspects of the nurse’s clinical interactions with patients, supervisors, coworkers, and systems of care. Copyright © SLACK Incorporated

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Cronbach’s alphas for the subscales are shown in Table 1, ranging from 0.50 (for the two-item learning techniques subscale) to 0.80 (for the seven-item clinical problem-solving scale). In the independent validation sample (the confirmatory factor analysis), the same four factors provided an adequate fit for the observed data (␹2/df = 2.00, Confirmatory Fit Index = 0.86, Root Mean Square Error of Approximation = 0.06). This level of fit was considered acceptable, although a CFI value less than 0.90 still indicates room for improvement. The third section of the survey consisted of two open-ended questions that asked about the respondents’ reasons for choosing nursing as a profession and what they thought could have been done to improve their preparation for entry into nursing practice. Quantitative data were entered into SPSS version 19 software. Survey items and demographics were summarized using descriptive statistics and tests of association. Alpha was set at 0.05. Analysis of variance was used to compare data across sites. Missing data were omitted from each calculation if there were any missing data on a subscale. Responses to the narrative questions were analyzed by of the research team who collaborated face-to-face for the analysis. Key words from respondent narratives were independently identified by the two faculty researchers and two research assistants. The faculty investigators then applied a general inductive approach (Thomas, 2006) to identify the themes embedded in the responses, reconciling rival explanations until consensus was achieved. RESULTS Participants Demographics

Demographic profiles were analyzed by development and the validation sample of respondents (Table 2). There were no statistically significant demographic differences between the students in the three schools. The average respondent was 29 years old, female, Caucasian, and concurrently employed while attending school. Respondents were enrolled in either a traditional (48%) or an accelerated (51%) baccalaureate program. Sixty-five percent of respondents had a previous non-nursing degree; 98% had previous health care experience in various roles (e.g., nursing or medical assistant, volunteer, unit secretary, emergency medical technician, or advanced care partner). For the total sample, students had a mean grade point average of 3.74. The number of clinical hours required for completion of the senior practicum varied by institution: 144 hours at site A (35%), 180 hours at site B (43%), and 225 hours at site C (22%) (p < 0.0001). The mean number of primary preceptors each student had during their senior practicum was 1.62 (SD = 1.02; range = 1 to 10). The following clinical placement areas for the senior practicum were reported: adult medical-surgical (27%), adult intensive care unit (20%), obstetrics (12%), pediatrics/ neonatal intensive care (17%), emergency department (10%), rehabilitation (2%), operating department (2%), and other (10%). Thirty-two percent of students were required to review NCLEXRN questions in addition to their curricular requirements. Skills/Procedure Performance

Three percent (n = 14) of respondents believed they were independent in all skills. Of 47 self-identified skills and proceJournal of Nursing Education • Vol. 50, No. 11, 2011

TABLE 2 Sample Demographics (N = 429) Demographic

Development (n = 162)

Validation (n = 267)

30.4

28.4

Age (years) Mean SD

6.9

7.1

21-53

21-59

Female

146

237

Male

16

30

White

142 (88%)

227 (85%)

Asian

8 (5%)

10 (3.5%)

Hispanic

5 (3%)

13 (5%)

African American

5 (3%)

5 (2%)

Range Gender

Ethnicity

Native American

0 (0%)

2 (1%)

Other/unknown

2 (1%)

10 (3.5%)

Traditional

42 (26%)

162 (61%)

Accelerated

120 (74%)

98 (37%)

0 (0%)

4 (1%)

Program type

Worksite Other

0 (0%)

4 (1%)

Currently employed

83 (51%) 18.0 hours (SD = 8.8) worked per week

165 (62%) 12.4 hours (SD = 11.2) worked per week

dures they were uncomfortable performing independently, the top 10 reported are listed in Table 3. Comfort/Confidence Subscales

Clinical Problem Solving (7 items). Participants were comfortable communicating with interdisciplinary team (mean = 3.20, SD = 0.57), yet they had a relatively low level of confidence communicating with physicians about patient care issues (mean = 2.88, SD = 0.68). They were confident in their ability to problem solve (mean = 3.29, SD = 0.52), identify actual or potential safety risks (mean = 3.28, SD = 0.49), take actions to solve problems (mean = 3.19, SD = 0.48), and use current evidence to make clinical decisions (mean = 3.22, SD = 0.53). Respondents did not feel comfortable knowing what to do for a dying patient (mean = 2.60, SD = 0.75). Learning Techniques (2 items). Respondents reported that simulation experiences were helpful in feeling prepared for clinical practice (mean = 2.63, SD = 0.85) and that writing reflective logs provided insights into clinical decision-making skills (mean = 2.37, SD = 0.81). Professional Identity (5 items). Communicating with patients and family was a skill most respondents were comfortable performing (mean = 3.47, SD = 0.55). Asking for 649

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TABLE 3 Top 10 Skills/Procedures that Cause Discomfort in Senior Practicum Students (N = 401) n (%)

Skill/Procedure Responding to an emergency/code/changing patient situation

152 (38)

Venous access (includes blood draw and IV starts)

148 (37)

Chest tube care

143 (36)

EKGs and telemetry—monitoring/interpretation

111 (28)

Tracheostomy care/suctioning

81 (20)

NG tube placement/Dobhoff care

80 (20)

Medication istration (includes IV medications)

54 (13)

Urinary catheter insertion/care

52 (13)

Wound care

44 (11)

Assessment

40 (10)

Note. IV = intravenous; EKG = electrocardiogram; NG = nasogastric.

Figure. Level of confidence managing a patient care assignment.

students (5%) did nothing to prepare for their clinical experience; 69 students (16%) listed other preparation activities, such as organizing daily assessment and work sheets; reviewing medical-surgical class, clinical notes, and pertinent resources such as textbooks and articles; and studying common medications and procedures completed previously. NARRATIVE RESPONSES Selection of Nursing as a Career

help from others was also acceptable and comfortable (mean = 3.66, SD = 0.50). Respondents were satisfied with their choice of nursing as a career (mean = 3.61, SD = 0.55) and felt ready to assume the professional nursing role (mean = 3.24, SD = 0.59). They also believed their clinical instructor provided about readiness to assume a RN role (mean = 3.31, SD = 0.70). Trials and Tribulations (6 items). Respondents were comfortable delegating tasks to the nursing assistant (mean = 3.03, SD = .62). Few reported having difficulty prioritizing patient care needs (mean = 1.87, SD = 0.56), recognizing a significant change in the patient’s condition (mean = 1.81, SD = 0.56), and documenting in the electronic medical record (mean = 1.65, SD = 0.66). Less often, respondents felt overwhelmed by ethical issues associated with patient care responsibilities (mean = 1.79, SD = 0.59). Practicing skills more than once (mean = 3.21, SD = 0.63) was a strategy used by students to increase their self-confidence. Patient Care Assignment

Responses varied when respondents were asked “What is your current level of confidence in managing a patient care assignment on an adult medical-surgical unit?” (Figure). There were no differences by age, type of nursing program enrolled (traditional versus accelerated), or past health care experiences related to level of confidence in managing a patient care assignment. There was little correlation between confidence in caring for the number of patients and the number of clinical hours completed during the senior practicum experience. Preparation for Senior Practicum Experience

In response to the question “What did you do to prepare for your senior practicum experience?,” students were able to select more than one response. Results are listed in Table 4. Twenty 650

The first open-ended question (“Why did you select nursing as a career?”) initially appeared as a checklist on the pilot survey. After the survey had been istered three times during the 2007-2009 period, the checklist was deleted and the question was fielded as an open-text inquiry. Responses from both the checklist and the open-text option were collapsed in this tally of themes. Numbers totaled greater than participants in the tally because students were free to select as many as applicable in the original checklist and the free-text response field was unlimited. Fifteen (3%) of the 429 survey respondents did not respond or were “not sure why.” Three themes emerged from the data: altruism, career strength, and opportunity for application of knowledge. Altruism. Of respondents, 351 identified words or phrases referred to the altruistic appeal of the nursing profession, such as caring and helping (211 students), making a difference (72 students), interacting with people (60 students), and being “called” to the profession (8 students). This most frequently emerging theme suggested that many students chose nursing as a career because it is “about the people.” They particularly valued both relationships and interaction and viewed nursing as “rewarding.” Career Strength. Of respondents, 253 referred broadly to what is described as the career of nursing itself; 146 respondents referred to the pragmatic aspects of the career. Salary, flexible schedule, job security, and the potential for career advancement were the key descriptors of this subtheme. Also embedded in this theme was the image of nursing itself, with the response “I’ve always loved nursing” being the purest reference to this subtheme. Many respondents had personal experience with nursing through exposure during times of illness or a tradition of nursing in their family. Of note for nurse educators, 17 students referenced image in the context of medicine: “I’ve always loved medicine, so I chose nursing.” Copyright © SLACK Incorporated

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Opportunity for Application of Knowledge. Of respondents, 92 stated that nursing appealed to them because it incorporates the use of science and a specific skill set to their work with people. They used the words “challenging” and “intellectual” to describe how they viewed work in this field.

TABLE 4 Preparation Activities for Senior Practicum Experience (N = 429) Activity

n (%)

Preparation to Enter the Nursing Profession

Discussed personal learning needs with faculty

309 (72)

Six themes emerged from the second open-ended question (What can be done to help you feel more prepared to enter the nursing profession?). Fifty (20%) of the 429 survey respondents gave no answer to this question. Some responses fell into more than one theme. Clinical competency was emphasized; 108 students alluded to the need for more clinical hours, simulation, or skill practice to become better at assessment and more equipped to respond to emergency situations. Fourteen responses referred to a more didactic emphasis, with students wanting greater confidence in their knowledge of pharmacology, laboratory value interpretation, and end-of-life care. Role development (29 responses) was identified as an area of improvement; students cited a need to communicate with physicians, gain independence, and learn electronic documentation systems. Only five respondents mentioned a benefit to working as a Certified Nursing Assistant or learning from allied health professionals as an important part of role development. Students (10 responses) expected better faculty (those with recent clinical experience), better preceptors (those trained to precept and interested in working with students), and better educational quality overall. Students also saw a need for more career planning (18 responses). Students specified preparation for job placement, preparation for the NCLEX-RN, development of job interview skills, help with resume building, and opportunities to experience different specialties in nursing. Postgraduate clinical experiences (4 responses) were also recommended by students who sought internships or mentoring in their first job.

Oriented to facility/tour unit

290 (68)

DISCUSSION

Findings in this study raise more questions than answers regarding perceptions of readiness for practice. Certainly, they help broaden our understanding of the senior nursing student’s perceptions of readiness and confidence for the professional nursing role. Interestingly, the skills that students voiced difficulty in performing are similar to skills that graduate nurses have difficulty mastering (Casey et al., 2004; Fink et al., 2008; Kovner et al., 2007). Overall, the students are very confident in their communication skills with patients and families and in asking for help from others. The biggest confidence needs seemed to center on the management of care: delegation of tasks, handling a multiple patient assignment, calling the physician, responding to a change in patient condition, and treating a patient who is dying. Students need opportunities to practice their conflict management skills, delegation of tasks, defending decisions made, and assertiveness in handling verbally abusive situations. Learning more about the specific clinical settings for senior practicum may provide additional evidence regarding what learning experiences present for the students to manage. We do Journal of Nursing Education • Vol. 50, No. 11, 2011

Brought medication reference or PDA to clinical

283 (66)

Set daily goals with preceptor

272 (63)

Participated in simulation assignment

147 (34)

Met with preceptor prior to start of clinical

146 (34)

Practiced skills in learning laboratory

106 (25)

Developed a care plan

64 (15)

Did nothing to prepare

20 (5)

Other

69 (16)

know that students had a small number of preceptors to guide their learning and that a clinical faculty member was available to provide and to the student. A majority of the students reported they entered the profession of nursing for the opportunities to care and help others. They are attracted to the flexible schedules, the image of nursing, and their past experiences providing care to others as career strengths. It appears they continue to see this in their clinical experiences as students, and this provides the desire to enter nursing with high hopes and confidence. Results from this survey may provide evidence to course enhancements that facilitate students’ successful transition into professional nursing practice. This study did not provide a consistent number of hours required to gain confidence and readiness for practice. Does the number of clinical hours taken equate with readiness? We are assuming that a senior practicum course is the best preparation for enhancing readiness for practice. Limitations

Although the overall response rate by senior nursing students was high, survey distribution by Zoomerang at one of the study sites resulted in a lower percentage of responses, which may have affected the validity of the results. Second, the diversity of study sites, while permitting a broader view of senior student experiences, also meant greater variability of educational methods and environments. The number of clinical senior practicum hours varied by site; preceptor training was not standardized at all sites; and the number of preceptors assigned to each student varied. Furthermore, clinical placements for the senior practicum occurred in multiple clinical facilities with varying levels of patient acuity. Future Research

Students bring their unique personality traits, past accomplishments, and life experiences to their nursing education programs. Further research is needed to validate what new knowledge and competencies these senior nursing students bring to the practice setting in regard to clinical problem solving, 651

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decision making, team leadership, and cultural aspects of interpersonal relationships because these factors may influence the education-practice gap. This gap between the knowledge and skills nursing students learn in the education setting and those needed to function safely and independently in the practice setting deserves more study. Developing an education-practice shared understanding of the readiness for practice concept may provide additional evidence to improved strategies for the preparation, transition, and integration of new graduates into the nursing workforce (Wolff, 2010). It would be important to revise the survey tool (item reduction) based on the study findings and conduct a larger study to further examine the characteristics of nursing students and nursing education programs with and without a senior practicum experience and look at multiple degree types in various geographic locations. CONCLUSION

Senior nursing students perceive they are ready for professional nursing practice. There is a mismatch in their perceptions of readiness for practice and what they are telling us as newly graduated nurses. A senior practicum course, offered during the final semester prior to graduation, provides one-on-one guidance and opportunities for students to dialogue about differences between expectations and realities of the workplace. The senior practicum experience may be an effective and innovative means to facilitate the development of student clinical competence and confidence for practice. The education of nurses is the foundation on which quality and patient safety are built. New technologies require graduates to work quickly, efficiently, and safely. It is critical that students be prepared to meet clinical challenges that they may not have encountered directly, but for which they must be prepared. REFERENCES American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from http://www.aacn.nche.edu/education/pdf/BaccEssentials08.pdf Beecroft, P., Kunzman, L., Taylor, S., Devenis, E., & Guzek, F. (2004). Bridging the gap between school and workplace. Journal of Nursing istration, 34(7/8), 338-345. Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. Berkow, S., Virkstis, K., Stewart, J., & Conway, L. (2008). Bridging the preparation-practice gap, Volume I: Quantifying new graduate nurse improvement needs. Washington, DC: Nurse Executive Center, Advisory Board Company. Burns, P., & Poster, E. (2008). Competency development in new ed nurse graduates: Closing the gap between education and practice. The Journal of Continuing Education in Nursing, 39, 67-73.

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Candela, L., & Bowles, C. (2008). Recent RN graduate perceptions of educational preparation. Nursing Education Perspectives, 29, 266-277. Casey, K., Fink, R.M., Krugman, M., & Propst, J. (2004). The graduate nurse experience. Journal of Nursing istration, 14, 303-311. Chappy, S., Jambunathan, J., & Mamocha, S. (2010). Evidence-based curricular strategies to enhance BSN graduates’ transition into practice. Nurse Educator, 35, 20-24. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. (2010). A summary of the February 2010 forum on the future of nursing: Education. Retrieved from http://www.nap.edu/catalog.php?record_id = 12894 Duchscher, J. (2008). A process of becoming: The stages of new nursing graduate professional role transition. The Journal of Continuing Education in Nursing, 39, 441-450. Fink, R.M., Krugman, M., Casey, K., & Goode, C. (2008). The graduate nurse experience: Qualitative residency program outcomes. Journal of Nursing istration, 38, 341-348. Goode, C., & Williams, C. (2004). Post-baccalaureate nurse residency program. Journal of Nursing istration, 34, 71-77. Goode, C.J., Lynn, M.R., Krsek, C., Bednash, G.D., & Jannetti, A.J. (2009). Nurse residency programs: An essential requirement for nursing. Nursing Economic$, 27, 142-148,159. Harrison, T., & Stewart, S. (2007). Clinical focus program: Enhancing the transition of senior nursing students to independent practice. Journal of Nursing istration, 37, 311-317. Hickey, M.T. (2009). Preceptor perceptions of new graduate nurse readiness for practice. Journal for Nurses in Staff Development, 25, 35-41. Kovner, C., Brewer, C., Fairchild, S., Poornima, S., Hongsoo, K., & Djukic, M. (2007). Newly licensed RNs’ characteristics, work attitudes, and intentions to work. American Journal of Nursing, 107(9), 58-70. Kramer, M. (1974). Reality shock: Why nurses leave nursing. St. Louis, MO: C.V. Mosby. Krugman, M., Bretschneider, J., Horn, P.B., Krsek, C.A., Moutafis, R.A., & Smith, M.O. (2006). The National Post-Baccalaureate Graduate Nurse Residency Program: A model for excellence in transition to practice. Journal for Nurses in Staff Development, 22, 196-205. Li, S., & Kenward, K. (2006). A national survey of nursing education and practice of newly licensed nurses. JONA’S Healthcare Law, Ethics and Regulation, 8, 110-115. National Council of State Boards of Nursing. (2009). The impact of transition experience on practice of newly licensed ed nurses. Retrieved from http://www.ncsbn.org Preheim, G., Fuller, J., Jaynes, C., Matthews, E., & Ward, J. (2009). Syllabus for NURS 4128 senior integrated practicum. Course brief available from the University of Colorado, College of Nursing, 13120 E. 19th Avenue, Aurora, CO, 80045. Rush, K., Peel, K., & McCracken, B. (2004). Empowered learning on the inside: An externship experience. Nursing Education Perspectives, 25, 284-291. Thomas, D.R. (2006). A general inductive approach for analyzing qualitative evaluation data. American Journal of Evaluation, 27, 237-246. Wieland, D., Altmiller, G., Dorr, M., & Wolf, Z. (2007). Clinical transition of baccalaureate nursing students during preceptored, pregraduation practicums. Nursing Education Perspectives, 28, 315-321. Wolff, A.C., Regan, S., Pesut, B., & Black, J. (2010). Ready for what? An exploration of the meaning of new graduate nurses’ readiness for practice. International Journal of Nursing Education Scholarship, 7(1), 1-14.

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