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Marilyn H.Oermann PhD, RN,FAAN, Professor,

College of Nursing,

Wayne State

University, Detroit,

Michigan,

Michael F. GarvinMSN, RN,

Staff Nurse,

Department of

Veterans Affairs,

John D. Dingell

Medical Center,

Detroit, Michigan,

USA

(Requests for

offprints to:

MHO, 168 North

Cranbrook Cross,

Bloomfield Hills,

MI 48301-2508,

USA. Tel.: 1 248594 6933;

Fax: 1 248 5946934;

E-mail: moermann@

msn.com)

Manuscriptaccepted:19 September 2001

& 2002 Published by Elsevier

doi:10.1054/nedt.2001.0695,resses and challw graduates in

ilyn H. Oermann and Michael F. Ga

ew graduates enter the workplace, they are fanning practice. The nurse manager, preceptor, aific stresses and challenges experienced by newd and need to plan interventions for coping wigraduates face in clinical practice? To answer thlinical Stress Questionnaire on which they rateal practice and the extent they experienced 20atients on the unit. They also described whatarticle presents the results of this survey and gg the orientation period. & 2002 Published by

oductionknowledge and skills needed for entrynursing practice have expanded in recent. As graduates begin their orientation

rams, there is still much to be learned forice in most healthcare settings. Newuates may lack an understanding of theepts and theories for care of patients inarticular setting, they may have limitedological skills, and their clinical

riences as students may not haveuately prepared them for beginningice.r many new graduates, the orientationd can be arduous. In addition toiring competencies for patient care,uates also need to learn about the rolee nurse and how to cope with othernds, such as organizing care effectively,leting assignments on time, anding with unfamiliar staff. Much of theing that occurs during orientation is notin the classroom but takes place inal practice as graduates learn how tofor their patients and how to worktively in the agency.

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ed with many stresses associated withd nursing staff need to be aware of the

graduates during their orientationh them. What stresses and challenges dos question, 46 new graduates completed

their degree of stress and challenge inifferent emotions while learning to careas stressful and challenging for them.idelines for mentoring new graduatesElsevier Science Ltdrse managers, preceptors, and otherng staff have an important role inifying the clinical learning needs ofates, planning patient assignments tothose needs, and mentoring graduates somay cope more easily with the inherentes and challenges of beginning practice.tation programs are expensive for they. To get the most out of the orientation

d, new graduates need a consistentor, whether it be a manager, preceptor, orgue. Along with teaching new graduateserving as a role model, the mentor canthem cope with other stresses they face inning practice.ile some stress is motivating, too high a

interferes with learning (Gaberson &ann 1999). An understanding of thesees and the difficulties new graduatesin their initial practice on the unit enablesentor to more carefully plan learningiences and provide the assistance neededaduates to adjust to the practice setting.entor cannot effectively teach newates and cannot adequately support themut an understanding of the stresses,

Nurse EducationToday (2002) 22, 225230 225

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Stresses and challenges for new graduates

226 Nurse EducationTenges, and difficulties nurses experienceginning clinical practice.

pose

urpose of the study was to describe theses and challenges new graduatesrienced in their initial clinical practice initals. This survey of new graduatesds earlier studies in which graduates

rted a moderate amount of stress in clinicalice during the orientation period.

rature review

ies have shown that clinical practiceessful for new graduates and nursingnts. Oermann and Moffitt-Wolf (1997)ined the stresses and challenges of new

uate nurses during their orientation to theal setting, and the relationship of these tol support. Data were collected with thecal Stress Questionnaire (CSQ) (Pagana. New graduates reported a moderate

ee of stress in their orientation periodse of their lack of clinical experience

organizational skills. There were noficant relationships between socialort (having a preceptor and participatingrmal support groups) and degree ofs. Although graduates who hadptors and support groups on the unitot have less stress, they reported thatlearning experiences with patients weresatisfactory and stimulating. They also

loped more self-confidence than graduatesdid not perceive this support from theirptors or others on the unit.another study, Maben and Clark (1998)

viewed 10 new graduates on theirition from student to staff nurse.ugh these nurses consistently articulated

cts of their role that they found enjoyablesatisfying, all of them acknowledgedgs of stress. This stress was related toing increased responsibility, being tired,

ming patients and relatives of negativengs, working with terminally ill andndent patients, discharging patients too, and not having support from others.

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Otperspskillspatiedecisoday (2002) 22, 225230arnley (1999) conducted a similar studysemi-structured interviews of 18 newates. The interviews revealed that newates had significant stress and anxietyg the first 6 months in practice. Thee of this stress appeared to relate to thes' lack of confidence in their clinicalce skills and to work-overload, leadingduates' perception of their inability tor holistic care. The nurses alsoienced concern over the care deliveredistants, who often lacked knowledge

bility to interpret findings, and stressfeeling responsible for the care actually

ed by the assistants.a longitudinal study by Dearmun (1998),

iatric nurses within 1 year of graduatingnursing school in the UK wereiewed four times. Stresses reportedd to caring for children and workingheir families, assuming new tasks andnsibilities, and coping with work issuess poor staffing.

rsing students have also described theful nature of clinical practice. Using theOermann and Standfest (1997)ned the stresses and challenges ofg students (n 416) enrolled in

ent clinical courses in 10 randomlyed programs. There were significantences found across clinical courses.was highest for students enrolled in

tric courses and lowest for fundamentalses. Students also reported more stressical courses as they progressed

gh the nursing program, with the finalter before graduation being the mostful time for them (Oermann 1998).ing interviews and observations ofnts in the clinical setting, Wilson (1994)

that students had six major goals toin their clinical practice: to avoidng the patient, help patients, apply

to practice, develop clinical skills,good' as a student, and `look good' ase. Students were anxious about making a

ke that could harm the patient.er stresses, from the student's

ective, are lacking knowledge andfor patient care, the changing nature oft conditions, uncertainty about clinicalons, and working with difficult patients.& 2002 Published by Elsevier Science Ltd

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Stresses and challenges for new graduates

& 2002 Published by Elsevieracting with the teacher, nursing andr hospital staff, patients, and familybers and being observed and evaluatede clinical setting also are stressful forents (Gaberson & Oermann 1999,

ann & Lukomski 2001, Williams 1993,on 1994).his research has emphasized the need forort from the teacher and mentor to help

ents and new graduates cope with theses they experience in clinical practice.

portive relationships with the teachermentor lead to development ofconfidence and willingness to try newroaches to care, knowing that an expertailable to guide their decision-making.orking closely with students and new

uates in the practice setting andpting them as part of the team, theher and mentor develop a climate thatorts learning and critical thinking (Myrick

onge 2001). This climate, combined witheasing responsibilities for patient care,ortunity to practice skills, and consistentback and clinical supervision, promoteing in clinical practice (Lofmark &

blad 2001).

thod

xamine the stresses and difficulties newuates faced in clinical practice, weucted a survey of 46 new graduates in

e hospitals in the Midwest region of the. The nurses had been practicing as newuates for a mean of 2.74 months, and allem had completed the formal classroomponent of their orientation program. Theuates were from associate (n 26) andalaureate (n 20) degree nursingrams. They were working in medical/ical nursing (n 24, 52%), critical care17, 37%), and other units in the hospital5, 11%). Their mean age was 38.83 years 9.03). The study was approved by thetutional Review Boards of the universityparticipating hospitals.raduates completed the CSQ, which wasgned to assess the stresses, challengesemotions experienced by students incal practice (Pagana 1989). On the CSQrated, using a scale of 0 (none)

to 4chaltheylearalsotheand

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Tgradtheyr Science Ltda great deal), their degree of stress andnge in clinical practice and the extent

experienced 20 different emotions whileing to care for patients on the unit. Theyescribed in the open-ended questionspes of experiences that were stressfulhallenging for them.the original evaluation of the CSQ bya (1989), factor analysis supported its

ruct validity, and alpha coefficients wereen 0.84 and 0.85. Inter-rater reliabilitye open-ended questions was 0.89.Oermann and Standfest (1997) study,

pha coefficient for the CSQ was 0.85.contact person was identified in thedevelopment department at eachtal, to assist in identifying currentate nurses at their facility. The newates were asked in person to participatestudy. An envelope containingation about the study, the CSQ, and a

ed envelope for return were distributedh potential participant. The nursesd the completed instruments to thetigators. No names or code numbersused.

lts

ses and challenges of beginningal practice

graduates found beginning clinicalice on the unit moderately stressful;ean score was 2.30 (SD 1.05), on aof 0 (none) to 4 (a great deal). Evenh graduates found their clinicaliences to be stressful, they werenged by them to an even greatere (Mean 2.57, SD 0.96). A one-wayVA was used to determine if there wereences in the amount of stress andnge based on the type of unit in whichates were currently working. There was

eater stress or challenge if orienting tol care than to medical/surgical units.also were no differences based on the

of nursing program graduates hadleted.rough the open-ended questions, theate nurses identified several stresses

experienced during orientation to theNurse EducationToday (2002) 22, 225230 227

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se managers, preceptors, and otherorkers can help support and nurtureew graduate. If there is no formal

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Stresses and challenges for new graduates

228 Nurse EducationT. The stresses reported most frequently: (1) not feeling confident and competent,aking mistakes because of increased

kload and responsibilities, and (3)untering new situations, surroundings,procedures. Other stresses are presentedble 1.

he greatest challenges faced by the newuates were applying the knowledge theyed in school to their patients' careacquiring new skills. Other challengesassuming an increased patient

nment and more responsibilities,roving organizational ability and clinicalment, and caring for critically ill patients.sing Pearson r, there were no significantionships between the degree of stressthe graduate's age, months of experiencenew graduate, years of past workrience, and years of experience as ae technician. There also were noificant relationships between the degreeallenge and any of these variables. Therears to be a certain amount of stress and

lenge associated with beginning practice

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feeling confident and competenting mistakes because of increased workload andponsibilitiesountering new situations, surroundings,d proceduresnsistent preceptors

ting to know the staffounters with unhappy nurses and other personnelrt staffingf nurses who were unwilling to help them

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StimuHopeExciteHappEageAnxioExhilOverPleasConfApprWorrIntimRelieFearfDisapDisguSadAngrGuiltrdless of the graduate's age and priorcal experiences.

tions experienced bygraduates

graduates rated the extent to whichexperienced 20 different emotions in

nning clinical practice. Of the 11tions experienced most frequently, withn scores greater than 2, most were positive.ever, new graduates reported that theyfrequently anxious about caring for

nts and encountering new clinical

a menassignlearnithey nThe mwhomquesttypicapractinot femanaand wmista

oday (2002) 22, 225230iences (mean 2.46), overwhelmed byassignments (mean 2.32), andhensive about caring for patients 2.07) (Table 2). While most of the

ates experienced positive emotions inning practice, their anxiety in caring forts and with new clinical experienceseing overwhelmed are importantgs of this study.

2 Emotions experienced during clinicale

n Mean SD

ted 2.75 0.89l 2.71 0.90

2.68 0.772.68 0.722.54 1.17

s 2.46 1.04ated 2.36 0.91helmed 2.32 1.12

2.25 0.84ent 2.11 0.88ensive 2.07 1.15d 1.64 1.13ated 1.61 0.79d 1.57 0.69

1.36 0.62ointed 0.93 0.90ed 0.82 1.25

0.68 0.820.64 0.870.54 0.88tor on the unit to make their patientments, consider their individualng needs, and provide the instructioneed to develop clinical competencies.entor also serves as the expert withthe graduate can consult and ask

ions. The mentor should be aware ofl stresses graduates face in beginningce new situations and procedures,eling competent, difficulties inging increasing patient responsibilitiesorkload, and concern about making

kes.

& 2002 Published by Elsevier Science Ltd

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Stresses and challenges for new graduates

& 2002 Published by Elsevieurses working with new graduates,to be realistic about their expectations

e graduates particularly as they relate tocal knowledge, critical thinking andsion-making, and technical skills. All too

experienced nurses set too high adard of care for new graduates. Whilee graduates may meet these standardsthe expectations of the mentor, othersneed more time to develop theirledge and skills.

ching new graduates:t is involved?

teacher, the mentor recognizes thevidual differences of each graduate ande range of competencies they bring to

first nursing position. Rather thaning the new graduate as someone whot competent for practice on the unit,ad the mentor plans patient assignmentslearning activities that enable theuate to develop the competencies that

lacking.urses enter practice with varying levels

nowledge and skills and different types ofcal experiences. The mentor's firstonsibility is to assess the present level of

ledge and skill of the graduate. Thisides the basis for planning assignmentsexpand the nurse's knowledge base and

the nurse to practice essential skills.ses need to practice what they are learning;experience in caring for a patient ororming a new skill is not enough tome proficient. Opportunities to practices and receive feedback facilitate learning incal practice (Lofmark & Wikblad 2001).ne predominant stress reported by thegraduates in this study was making

akes because of increased workloadresponsibilities. Graduates also viewedas a challenge to be met as they adaptede work setting. In planning patientnments, the mentor should gradually

ease workload and patientonsibilities. Being available to help thee in organizing care and in makingcal judgments will provide the supported for graduates to meet the challenges

eginning practice.

Tintothethe`debdiscaltediscnuraristhoumenrelyconthehos

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A`difuniimpmatshoundandandnurwillr Science Ltdo other strategies easily incorporatedhe mentor's role are: (1) meeting withew graduates periodically throughoutay to answer questions; and (2) having aiefing' session at the end of the day, forssion of problems encountered andate ways of solving them. In thesessions the mentor also can guide thein handling difficult situations that may

with patients and staff. These strategies,h, are only effective with a consistent

or to whom the graduates can turn andn during orientation. The lack of a

stent preceptor was a stress identified byew graduates surveyed across all threetals.e next step in the process of teachinggraduates is to guide nurses to acquiretial knowledge and skills for practiceo develop self-confidence. Guidanceves teaching about diagnoses,entions, and other aspects of patientn which the graduate is unsure,nstrating new procedures andiques, questioning nurses to expandunderstanding of a clinical situation,ding feedback and reinforcement, andg as a role model.

actions with staff

f the most important conclusions thate drawn from this study is thertance of the interactions andunications that occur during orientation.

uates reported that when they had openunication with the manager, preceptor,thers, and when they viewed these

le as supporting them on the unit, thisction facilitated their learning andopment of self-confidence.ong the same line, having to work withult' nurses and other personnel on theas a stress for new graduates. This has

cations for identifying mentors anding them with graduates. Mentors

d be expert clinicians, have anrstanding of the role of the mentorow to teach, work well with others,e enthusiastic about their role as a. Strong interpersonal skills andgness to work with others are essentialNurse EducationToday (2002) 22, 225230 229

characteristics of an effective clinical teacher(Gaberson & Oermann 1999).

Conclusions

Although the importance of establishingsupportive relationships with new graduates isdocumented in the literature, this remains anarea in need of improvement. It is up to thenurse manager, preceptor, and otherexperienced nurses to work toward developingtrusting and caring relationships with newnurses on the unit. A trusting and supportiverelationship between the mentor andnew graduate makes this learning lessstressful.

References

Charnley E 1999 Occupational stress in the newly qualifiedstaff nurse. Nursing Standard 13(29): 3236

Dearmun AK 1998 Perceptions of job stress. Journal ofChild Health Care 2(3): 132137

Gaberson K & Oermann MH 1999 Clinical teachingst

Lofmark A & Wikblad K 2001 Facilitating and obstructingfactors for development of learning in clinical practice:A student perspective. Journal of Advanced Nursing34(1): 4350

Maben J & Clark JM 1998 Project 2000 diplomates'perceptions of their experiences of transition fromstudent to staff nurse. Journal of Clinical Nursing7: 145153

Myrick F & Yonge OJ 2001 Creating a climate forcritical thinking in the preceptorship experience.Nurse Education Today 21: 461467

Oermann MH 1998 Differences in clinical experiencesof ADN and BSN students. Journal of NursingEducation 37(5): 197201

Oermann MH & Lukomski AP 2001 Experiences ofstudents in pediatric nursing clinical courses. Journalof the Society of Pediatric Nurses 9(2): 6572

Oermann MH & Moffitt-Wolf A 1997 Graduate nurses'perceptions of clinical practice. Journal of ContinuingEducation in Nursing 28: 2025

Oermann MH & Standfest KM 1997 Differences instress and challenge in clinical practice among ADNand BSN students in varying clinical courses.Journal of Nursing Education 36: 228233

Pagana KD 1989 Psychometric evaluation of theclinical stress questionnaire (CSQ). Journal ofNursing Education 28: 169174

Williams RP 1993 The concerns of beginning nursingstudents. Nursing & Health Care 14: 178184

Wilson ME 1994 Nursing student perspective of learning inl

Stresses and challenges for new graduates

230 Nurse EducationTrategies in nursing education. Springer, New York a coday (2002) 22, 225230inical setting. Journal of Nursing Education 33: 8186& 2002 Published by Elsevier Science Ltd

IntroductionPurposeLiterature reviewMethodResultsTable 1Table 2

ConclusionsReferences