Senior BSN students’ confidence, comfort, and perception of readiness for clinical practice: the impacts of COVID-19

Eyad Musallam; Brooke A. Flinders

doi:10.1515/ijnes-2020-0097

Article Publicly Available

Senior BSN students’ confidence, comfort, and perception of readiness for clinical practice: the impacts of COVID-19

Eyad Musallam and Brooke A. Flinders

Published/Copyright: April 22, 2021

Published by

Become an author with De Gruyter Brill

Submit Manuscript Author Information Explore this Subject

From the journal International Journal of Nursing Education Scholarship Volume 18 Issue 1

Abstract

Objectives

The Coronavirus Disease 2019 (COVID-19) has impacted overall nursing education program requirements, classroom delivery of theory hours, as well as clinical and laboratory learning opportunities for students. The aims of this study were to explore the impacts of COVID 19 on the students’ perceptions of readiness for practice and their preparation for the NCLEX exam and initial clinical practice.

Methods

A cross-sectional descriptive design was used to investigate the impact of COVID-19 on senior BSN students’ preparation for NCLEX and future careers. The Casey-Fink Readiness for Practice Survey was used to investigate the perceptions of the BSN students’ clinical confidence and readiness for practice.

Results

Students reported substantial impacts of COVID-19 on their clinical experiences, their ability to practice skills and procedures, their preparations for NCLEX exam, and their nursing career. The most significant confidence concerns noted from this study seemed to center on handling multiple patient assignments, calling the physician, responding to a change in patient condition, and treating a dying patient.

Conclusions

Healthcare experts expect that the impact of COVID-19 may last until 2022. More research is needed to understand the impact of COVID-19 on nursing education and transition to nursing practice. While clinical confidence and readiness for practice are essential topics, more research is needed to investigate the psychological and physiological impacts of COVID-19 on nurses, nursing students, nursing preceptors, and faculty members.

Keywords: clinical education; COVID-19; NCLEX; nursing education

Introduction

Nursing students must be prepared to enter the healthcare environment ready to practice safely, effectively, and compassionately (Kavanagh & Szweda, 2017). The goal of nursing programs is to adequately prepare students to enter the nursing profession (Rosseter, 2014) and it is an expectation that most skills and competencies needed for entry to practice be acquired within the educational program attended (Casey et al., 2011; Kavanagh & Szweda, 2017). Bachelor of Science in Nursing (BSN) students actively participate in classes, clinical practice rotations, skills labs, and simulation experiences throughout their nursing education. However, students do not always report confidence or readiness to perform all skills or to provide care in particular clinical situations (Casey et al., 2011; El Haddad, Moxham, & Broadbent, 2017; Oblea, Berry-Caban, Dumayas, Adams, & Beltran, 2019; Wolff, Pesut, & Regan, 2010). Newly graduated registered nurses (RNs) often report high-stress levels when transitioning into practice (Hickerson, Taylor, & Terhaar, 2016). In fact, 25% of new graduates have been reported to have left their jobs due to the high levels of anxiety related to practice errors and patient safety concerns (Hickerson et al., 2016). They have self-reported a desire for additional clinical time, more practice with technical skills, a broader range of real-life practice experiences, and more opportunities for communicating with healthcare providers during their educational programs (Hickerson et al., 2016; Mirza, Manankil-Rankin, Prentice, Hagerman, & Draenos, 2019; Oblea et al., 2019).

In 2020, the Coronavirus Disease 2019 (COVID-19) impacted, among other things, nursing education programs, scheduled classroom instruction, and clinical experiences (NCSBN, 2020). Many, if not all, educational programs pivoted quickly to offer previously face-to-face classes and labs online in response to the pandemic. Some clinical settings were forced to restrict or prohibit the clinical education of students in their settings due to the outbreak (NCSBN, 2020; Pragholapati, 2020). As a direct result of COVID-19, many nursing programs were challenged to find alternative modalities to meet course objectives and to fulfill clinical and laboratory hours identified as program requirements. In spring 2020, Nursing Regulatory Bodies (NRBs) in the United States (US) established acceptable alternative standards to facilitate the completion of nursing education clinical experiences, despite COVID-19 (NCSBN, 2020). There are countless examples of state by state allowances which had to be made in response to the pandemic. One such example occurred in Kentucky, where the governor approved the Board of Nursing’s memorandum to allow exceptions to the standard requirements of completing 120 h of direct patient care in an integrated practicum during seven consecutive weeks. In that state, simulation experiences were accepted to replace up to 100% of the typical integrated practicum clinical hours (NCSBN, 2020) and provisional licensure for new graduates was permitted during 2020. In the state of Michigan, the Board of Nursing allowed 100% virtual simulation, or other clinically related online activities, to replace clinical experiences. A third example of a statewide response to COVID-19 occurred when the Arizona Board of Nursing permitted nursing programs to apply for waivers for the substitution of online teaching for face-to-face course delivery and the replacement of clinical hours with simulation (NCSBN, 2020).

COVID-19 has impacted the delivery of overall nursing education program requirements, classroom-based delivery of theory hours, as well as clinical and laboratory learning opportunities for students, thus possibly affecting nursing students’ feelings of readiness and confidence to practice. The aims of this study, therefore, were to explore the following questions:

With which clinical practice skills did senior BSN students feel the least comfortable or confident when their education was modified due to COVID-19?
What were students’ perceptions of readiness for practice in a professional nursing setting when their educational experience was modified due to COVID-19?
What were the impacts of COVID-19 on senior-level BSN students’ preparation for taking the National Council Licensure Exam (NCLEX) and for initial clinical practice?

Literature review

Although nursing curricula may vary over time, based on setting and location, readiness for practice has been an internationally documented challenge for at least 50 years. For the purpose of this study, a narrative review was conducted to investigate the definitions of readiness for practice and the factors that influence the readiness for practice. PubMed® and CINAHL databases were searched using the following keywords: readiness for practice, confidence, undergraduate, and nursing.

Since 1970, concerns about new nursing students’ readiness for clinical practice have been raised, explored, and disseminated in the nursing literature, from a breadth of geographic locations. By 2008, undergraduate nursing programs were being guided by the American Association of Colleges of Nursing (AACN), through the “Essentials of Baccalaureate Education for Professional Nursing Practice”, to prepare students for the realities of professional practice environments of that time (AACN, 2008). This call to action was made to ensure readiness for newly licensed nurses. A few years later in Canada, Wolff et al. (2010) conducted an exploratory study to investigate the perceptions of readiness reported by 150 new graduates. As part of their perceived understanding of practice readiness, the students reported it was a necessity to provide students with experiences at the end of their education that represented “real life” situations, particularly in terms of managing workloads (Wolff et al., 2010). In 2020, in the Republic of Ireland, Leufer and Clearly-Holdforth (2020) found that senior-level nursing students reported concerns related to the management of medications, patient caseloads, and communication.

Readiness is described as the feeling or state of being fully prepared for a required action (Oxford Dictionary, 2018). Various definitions of readiness for practice are noted throughout the nursing literature. Wolff et al. (2010) defines the new graduate nurses’ readiness for practice as having a “generalist foundation” with specific capabilities related to the job, an ability to provide safe client care, awareness of the current state of nursing practice, being well-equipped with the necessary tools to adapt to the future client needs, and the possession of balance between “doing, knowing, and thinking”. Casey et al. (2011) define readiness for practice as being competent and having the knowledge, skills, and judgment required for one’s role. According to Mirza et al. (2019) readiness for practice characteristics include 1) cognitive capability (knowing how to use knowledge in a particular context or situation), 2) clinical capability (the ability to perform the necessary psychomotor skills), 3) professional capability (the ability to function independently and being accountable for one’s nursing practice), and 4) self-efficacy (belief in one’s readiness for practice). Actual readiness for practice contributes to improved client safety by reducing adverse events and decreasing nursing errors (Missen, McKenna, & Beauchamp, 2016; Murray, Sundin, & Cope, 2018) and is known to enhance the process of safety risk identification within practice settings (Missen et al., 2016; Murray et al., 2018).

Casey et al. (2011) used the Casey-Fink Readiness for Practice Survey to examine perceptions of readiness of 429 senior students upon completion of their practicum course. Students felt least confident in the areas of care management, delegation, handling multiple patient assignments, calling a physician, and responding to a change in a patient’s condition. The results also showed that the senior practicum experience is beneficial for students to gain confidence and competence; however, they must also be prepared for clinical situations that they had never experienced (Casey et al., 2011). Walker, Storey, Costa, and Leung (2015) utilized a 64-item Work Readiness Scale (WRS) to assess 450 newly RNs practice readiness. They found that specific attributes which make up practice readiness may not yet be clearly defined, but the skills that are lacking typically involve personal and relational competencies. Students do not necessarily learn these competencies within their educational settings (Walker et al., 2015).

Bowdoin (2014) conducted another study of readiness for practice. It included 110 pre-licensure nurses from diploma, associate degree, and BSN programs in the United States. This study reported that statistically significant predictors of greater perceived readiness for practice include: younger age, prior or current healthcare experience and greater professional competence. In another study, which focused on student demographics, Pillai (2014) reported that non-traditional students perceived more readiness, and increased readiness according to age. Additional factors to enhance the readiness for practice noted in the literature include: continuous review of nursing curricula to reduce the gap between academia and practice, use of simulations to improve practice skills, creation of formal mentorship programs, and implementation of nursing residency programs (Järvinen, Eklöf, & Salminen, 2018; Romyn et al., 2009; Rush, Janke, Duchscher, Phillips, & Kaur, 2019).

Theoretical model: stages of transition and transition shock

The Stages of Transition and Transition Shock model (see Figure 1) provides a framework for understanding the new graduate nurses’ transition to practice (Duchscher & Windey, 2018) and was selected to guide the current study conceptually. The authors describe transition as developing through three main stages: doing, being, and knowing (Duchscher & Windey, 2018). These three phases are overarched by transition shock which usually occurs in the first three to four months of transition, and transition crisis, ending at approximately eight to nine months into a nurse’s initial year of clinical practice (Duchscher & Windey, 2018). Transition shock results from the disparities which exist between the relationships, roles, responsibilities, knowledge, and performance expectations of a student and those of an RN in the professional practice setting (Duchscher & Windey, 2018).

Figure 1:

Duchscher’s stages of transition theory.

In the doing stage (first three to four months), the newly licensed nurse moves from the structured, expected educational context to the responsibilities of professional work. In this stage, the new nurse feels increasing levels of intensity and anxiety because of the overwhelming, unfamiliar aspects of professional practice, and spends most time in tiresome cycles of preparing for and then debriefing about clinical practice (Duchscher & Windey, 2018). The being stage of professional role transition occurs over the next four to five months and consists mainly of steady and rapid progression in thinking, knowledge level, and skill competencies. The new nurse begins to become increasingly comfortable with the nurse roles and responsibilities (Duchscher & Windey, 2018). The knowing stage represents the final stage of development for the newly licensed nurse. In this stage, the nurse shows signs of progressive development, able to answer questions instead of always asking them, and having the time and energy to assist others with their workloads. The new nurse develops an ability to manage complex clinical situations and a confidence in the performance of nursing skills and competencies (Duchscher & Windey, 2018). Based on the Stages of Transition and Transition Shock model, the current study hypothesized that the modifications to planned educational activities and clinical experiences/rotations which occurred as a result of COVID-19 would negatively impact the students’ perceptions of readiness for practice and could lead to an increase in both the intensity and the duration of the transition shock for newly licensed nurses.

Methods

Study design and sample

A cross-sectional descriptive design was used to investigate the impact of COVID-19 on 26 senior BSN students’ preparation for NCLEX and future careers. The convenience sample was drawn from a medium size nursing program in the Midwest USA. In the senior capstone experience, each student works closely with a preceptor/RN who has at least 24 months of professional nursing experience. Students collaborate with their clinical instructors to develop their clinical schedules and to complete 120 clinical hours with their designated preceptors. The senior capstone experience is a 15 weeks clinical course which takes place each spring semester. In 2020, the face-to-face practice period for study participants began in the first week of February, but switched to remote delivery in mid-March due to COVID-19. The missing clinical hours were replaced with simulation experiences so that course objectives could still be met. The students completed the survey for this study at the end of the spring semester, in May, 2020.

The Casey-Fink Readiness for Practice Survey (Casey, 2019) was used to investigate the perceptions of senior BSN students’ clinical confidence and readiness for practice. Estimates of internal consistency reliability for the Casey-Fink Readiness for Practice Survey factors ranged from 0.73 to 0.94. Cronbach’s alphas for the Casey-Fink Readiness for Practice Survey subscales ranged from 0.50 for the 2-item learning techniques subscale to 0.80 for the 7-item clinical problem-solving scale (Casey, 2019).

Students were asked to identify the top three skills or procedures that they felt most uncomfortable performing independently from a list of 18 skills and procedures. Next, students were asked about their level of confidence in managing multiple patient assignments, ranging from caring for four patients to two patients using a Likert scale with a range of 1–5, with 1 being not confident and 5 being Very Confident. After that, students were presented with a list of 20 items asking for a self-report about their level of comfort/confidence in performing key nursing activities using a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). This confidence survey included four key domains: 1) clinical problem solving, 2) learning techniques, 3) professional identity, and 4) trials and tribulations. The third section of the questionnaire consisted of four open-ended questions asking respondents about the COVID-19 impacts on clinical experience, NCLEX preparation, and their upcoming nursing careers.

Data collection and analysis

Approval was received from the University’s Institutional Review Board. All surveys were completed anonymously and contained no identifying information. The data were collected and stored using Qualtrics XM. A consent form was provided for each participant as a cover page for the online survey. Data were analyzed using an excel spreadsheet and SPSS version 26 software. Descriptive statistics were used for data analysis: frequencies and percentages were used to describe categorical variables while mean and standard deviations were used to describe continuous variables. Free-response answers were studied, and keywords were identified to categorize responses into themes.

Results

Demographic data and variables describing senior practicum experience

The mean age for participants was 26.8 (SD= 5.1); the total number of participants was 26, 4 were male (15.4%), and 22 were female (84.6%). The participants were Caucasian (n=23, 88.5%), black (n=2, 7.7%) and Asian (n=1 3.8%). In response to the question, “What previous health care work experience have you had?”, the majority of respondents in the first survey reported having had nursing assistant experience (n=16, 69.6%). On average, the students worked 14.1 h/week (SD=11.7) outside their clinical hours while in the nursing program. Clinical practicum experiences were located in Adult Medical Surgical (n=7, 29.2%), Emergency Department (n=4, 16.7%), and Pediatric Medical Surgical (n=3, 12.5%). On average, the students completed 44 (SD 15) clinical hours in their practicum and spent on average 7.1 h (SD=16.7) with a charge nurse. See Table 1.

Table 1:

Frequencies of categorical variables describing senior practicum experience.

Variables	n	%
Gender
Female	22	84.6
Male	4	15.4
Race
Asian	1	3.8
Black	2	7.7
Caucasian (white)	23	88.5
What previous health work have you experienced?
Nursing assistant	16	69.6
Volunteer	2	8.7
Unit secretary	2	8.7
EMT – paramedic	2	8.7
Student externship	1	4.3
What is your clinical area of employment?
Adult M/S	7	29.2
Emergency department	4	16.7
Pediatric M/S	3	12.5
Adult ICU	3	12.5
Oncology/BMT	2	8.3
OB (L&D, POST PARTUM)	1	4.2
Pediatric ICU	1	4.2
Other	3	12.5

	M	SD

Age	26.8	5.1
GPA	3.5	0.2
Number of NCLEX questions completed	40	60.7
Clinical hours completed	44	15
Hours spent with charge nurse	7.1	16.7
Average # hours worked/week	14.1	11.7

Based on the data reported by the course coordinator, the senior capstone experience was cut short because of COVID-19 and the clinical hours completed varied from 20 to 75. Missed clinical hours were replaced with online simulation. One to three simulations were assigned to students for their varied remaining clinical time. Students who had completed less than 30 h of clinical time were required to complete three simulations. Students with 30–60 h of clinical time were required to complete two simulations. Students who completed 60–90 h of clinical time completed one simulation. Simulations were evaluated and credit was given for completion of the required simulations.

Skills/procedures students were most uncomfortable performing independently

Of the 18 skills that students reported feeling most uncomfortable in performing independently, the top-ranked nine are highlighted in Table 2. The top four skills reported were: central line care (dressing change, blood draws, discontinuing), chest tube care, bladder catheter insertion/irrigation, blood draw/venipuncture, and responding to an emergency/CODE cardiac arrest/changing patient condition.

Table 2:

Skills least comfortable performing independently.

Skills least comfortable performing independently	n	%
Central line care/charting/documentation	19	16.1
Chest tube care	18	15.3
Bladder catheter insertion/irrigation blood draw/venipuncture	16	13.6
Responding to an emergency/CODE/changing patient condition Trach care/suctioning	13	11
EKG/Telemetry monitoring and interpretation Giving verbal report	12	10.2
Intravenous (IV) medication administration Intravenous (IV) starts	11	9.3
IV pumps/PCA pump operation medication administration	9	7.6
NG tube/Pulse oximetry	8	6.7
Wound care/dressing change/wound vac	8	6.7

Comfort/confidence domains

Clinical problem solving (7 items)

Participants felt strongly confident in their ability to identify actual or potential safety risks to their patients (M=4.5, SD=0.7), and in their ability to problem solve (M=4.2, SD=0.8). Participants felt relatively less comfortable knowing what to do for a dying patient (M=3.5, SD=0.9). The participants felt strongly comfortable communicating and coordinating care with interdisciplinary team members (M=4.1, SD=0.8), but reported a relatively lower level of confidence when communicating with physicians (M=3.5, SD=1.2). See Table 3

Table 3:

Students’ level of comfort/confidence in performing key nursing activities.

Students’ level of comfort/Confidence in performing key nursing activities – Clinical problem solving question	M	SD
1. I feel confident communicating with physicians	3.5	1.2
7. I am confident in my ability to problem solve	4.2	0.8
12. I use current evidence to make clinical decisions	4.3	0.8
13. I am comfortable communicating and coordinating care with interdisciplinary team members	4.1	0.8
16. I feel comfortable knowing what to do for a dying patient	3.5	0.9
18. I feel confident identifying actual or potential safety risks to my patients	4.5	0.7

Students’ level of comfort/Confidence in performing key nursing activities – Learning techniques question	M	SD

14. Simulations have helped me feel prepared for clinical practice	3.9	1.3
15. Writing reflective journals/logs provided insight into my own clinical decision-making skills	3.1	1.3

Students’ level of comfort/Confidence in performing key nursing activities – Professional identity question	M	SD

2. I feel comfortable communicating with patients and their families	4.7	0.7
6. My clinical instructor provided feedback about my readiness to assume RN role	4.0	1.1
11. I feel comfortable asking for help	4.5	0.7
19. I am satisfied with choosing nursing as a career	4.7	0.7
20. I feel ready for the professional nursing role	3.8	1.0

Students’ level of comfort/Confidence in performing key nursing activities –Trials and tribulation question	M	SD

3. I am comfortable delegating tasks to the nursing assistant	4.1	0.9
4. I have difficulty documenting care in the electronic medical record	1.9	1.0
5. I have difficulty prioritizing patient care needs	2.2	0.9
8. I feel overwhelmed by ethical issues in my patient care responsibilities	2.3	1.1
9. I have difficulty recognizing a significant change in my patient’s condition	2.1	1.0
10. I have had opportunities to practice skills and procedures more than once	3.7	1.3

Learning techniques (2 items)

Participants reported that simulations helped them feel prepared for clinical practice (M=3.9, SD=1.3), but did not feel that writing reflective logs provided insights into clinical decision-making skills (M=3.1, SD=1.3).

Professional identity (5 items)

Respondents felt extremely comfortable communicating with patients and their families (M=3.28, SD=0.46), and asking for help (M=4.7, SD=0.7). Most agreed that their clinical instructor provided feedback about their readiness to assume the role of a nurse (M=4.0, SD=1.1). Participants reported that they did not feel very ready for the professional nursing role (M=3.8, SD=1.0); yet, they felt highly comfortable asking for help (M=4.5, SD=0.7). See Table 3.

Trials and tribulations (6 items)

Participants reported feeling highly comfortable delegating tasks to nursing assistants (M=4.1, SD=0.9). They did not feel that they had difficulty prioritizing patient care needs (M=2.2, SD=0.9) or recognizing a significant change in a patient’s condition (M=2.1, SD=1.0). Most participants agreed that they had the opportunity to practice skills and procedures more than once (M=3.7, SD=1.3). See Table 3.

Patient care assignment

Students were asked about their current level of confidence in managing a patient care assignment on an adult Medical/Surgical unit. Students felt extremely confident managing one (M=3.7, SD=0.5) or two (M=3.3, SD=0.7) patients. Caring for four patients was not a task in which students felt confident (M=2.5, SD=0.5). See Table 4.

Table 4:

Level of confidence managing multiple patient assignments.

Level of confidence managing multiple patient assignments	M	SD
1 patient	3.7	0.5
2 patients	3.3	0.7
3 patients	2.9	0.8
4 patients	2.5	0.5

COVID-19 impact

Students were asked about the impact COVID-19 had on their clinical experiences, their abilities to practice skills and procedures, their preparation for NCLEX exam, and their nursing career plans. They reported that the COVID-19 pandemic significantly impacted their clinical experiences (M=4.6, SD=1.0) and their ability to practice skills and procedures (M=4.5, SD=1.1). They reported a relatively lower impact of the COVID-19 situation on their preparations for NCLEX exam (M=3.1, SD=1.4) and on their plans for a nursing career (M=3.9, SD=1.2). See Table 5.

Table 5:

COVID-19 impacts.

COVID-19 impacts	M	SD
COVID-19 situation impacted my clinical experiences	4.6	1.0
COVID-19 situation impacted the ability to practice skills and procedures	4.5	1.1
COVID-19 situation impacted my preparations for NCLEX exam	3.1	1.4
COVID-19 situation impacted my nursing career plans	3.9	1.2

Students described the impact of COVID-19 on their clinical experiences stating: “…many facilities would not take students and volunteers during COVID-19 pandemic”; “…clinical hours were cut short because of the COVID-19…”; “…unable to complete the required clinical hours…”; and “…many departments were closed during COVID-19 because of low census.” They were “…hoping to have more experience prior to graduating…”. As well, they stated that “simulation and online activities replaced the clinical experience”, and “I did practice some, but not as much as I anticipated.”.

The impact of COVID-19 on preparations for the NCLEX exam was described in these ways: “…more experience would have helped me feel more prepared…”; “…we were still able to complete practice questions and tests, but I learn best in the classroom environment…”; and “…I missed not being able to speak to the professors one-on-one…”.

The students reported substantial impacts of COVID-19 on their nursing career plans. For example, job offers and work interviews were canceled and “…hospitals are on a hiring freeze”. One participant stated that “…due to low census, my job offer/contract was revoked” while another noted that “…I had interviews set up with hospitals, all were canceled…”

Discussion

This study’s findings begin to broaden the profession’s understanding of students’ perceptions of readiness for practice during the COVID-19 era. Students in this study reported substantial impacts of COVID-19 on their clinical experiences, their ability to practice skills and procedures, their preparations for NCLEX exam, and their nursing career plans. COVID-19 impacted both the quantity and quality of the students’ clinical training and hours and students perceived that COVID-19 cut their clinical experiences short. Many facilities could not accommodate students nor volunteers during the COVID-19 pandemic. Another issue found to impact the quality of the clinical experiences was that hospitals had to cancel elective procedures during the public health crisis. Pre-licensure nursing programs were forced to shift from teaching face-to-face to online course delivery in a matter of days to weeks. This shift impacted the students who learn best through hands-on experience and who benefit from interacting with professors and peers one-on-one or in a conversational manner. Students’ nursing career plans were also significantly impacted. Because of COVID-19, job offers/contracts were revoked, interviews were canceled, and some students were told that hospitals were on a hiring freeze. On the opposite end of the spectrum, many states created avenues for temporary licensure. It is too soon to fully realize how these swift changes in practice may have impacted career opportunities and plans.

Nursing students in this study reported feeling uncomfortable performing the following skills independently: chest tube care, bladder catheter insertion/irrigation, blood draw/venipuncture, and responding to an emergency/CODE Cardiac Arrest/changing patient condition. Similar results were reported in previous studies (Casey et al., 2011; Fink, Krugman, Casey, & Goode, 2008; Kovner et al., 2007; Wray, 2017; Young, 2019). Nursing programs must continue to seek strategies to integrate or focus on these learning opportunities in their curricula.

Overall, the students reported that they were very confident in their ability to identify actual or potential safety risks to their patients, to communicate and coordinate care with interdisciplinary team members, to communicate effectively with patients and families, and asking for help from others. These results are congruent with previous studies, which were conducted before COVID-19 (Casey et al., 2011; Fink et al., 2008; Kovner et al., 2007; Wray, 2017; Young, 2019).

Support for transition to practice

Previous literature supports the implementation of transition to practice programs to facilitate new graduates’ competence, confidence development, and readiness to practice (Hussein, Everett, Ramjan, Hu, & Salamonson, 2017). Duchscher and Windy (2018) specifically point out the following essentials for creating the “healthiest transition experiences” for newly licensed nurses. These include 1) having stable, supportive relationships both inside and outside of work, 2) being are assigned roles and responsibilities that appropriately align with their stages of transition and experience, 3) receiving provision of support and constructive feedback, 4) being familiar with expectations around skills performance and care delivery, 5) having opportunities to discuss complex cases with experienced nurses, 6) being supported to successfully respond to complex practice scenarios, 7) receiving positive reviews, and 8) being supported in influencing quality improvement policies and practice standards. Because the perceptions of readiness for practice during COVID-19 times have been found to closely align with those during more traditional times, established, evidence-based recommendations can and should be relied upon as a foundation to support transitioning nurses. Specific competencies that may require additional support during the pandemic, according to this study’s participants, include: handling multiple patient assignments, calling the physician, responding to a change in patient condition, and treating a patient who is dying.

Curriculum structures and consideration of competency-based pedagogy

An overarching barrier to student preparedness for practice may lie in the existing standard structures of nursing curricula. In the US and internationally, it is common for content delivery to be concentrated in the final two years of the nursing curriculum, rather than evenly distributed in a competency-based structure (Ambrose, Bridges, DiPietro, Lovett, & Norman, 2010; Morin, 2020). One potential strategy to help compensate for the unknowns that may come with a public health crisis, would be to accelerate nursing education’s movement from content-based to competency-based pedagogy. Although competency-based pedagogy may take a wide variety of forms, the most basic assumption across models is that students must demonstrate acquisition of knowledge, skills, attitudes, and specific competencies in order to progress (Hodges et al., 2019; Gravina, 2017). Distributing nursing content more evenly, with a focus on competence attainment, could ensure that graduates are prepared to practice safely, despite any potential unanticipated adjustments to or lapses in theoretical or clinical education delivery. Students could focus on mastering essential skill sets that are not entirely dependent upon scheduled curriculum delivery one particular semester or academic year.

Simulation is a second curriculum structure that can be effective in building competence. Nursing students in this study reported that simulation helped them to feel prepared for practice with patients. The use of high-fidelity clinical simulation, especially in light of the fact that many NRB’s have allowed for flexibility in simulation hours replacing some clinical hours during the COVID-19 pandemic, is one useful mechanism for bridging the gap between theory and practice.

Collaboration and information sharing

Nursing programs must be willing to collaborate and share lessons learned during periods intense change and uncertainty. Collaboration could take the form of online debriefing workshops or international conferences with a focus on problem-solving for education throughout a pandemic. Another possibility might be for international nursing associations, councils, and organizations to take the lead in promoting the transfer of strategies for targeted topics, such as mentoring, into broader, more global settings. For example, the American Nursing Association has designed a successful virtual mentoring program to match new RNs with more experienced nurses. This approach could easily be replicated in settings outside of the United States to support new graduate nurses. Nurse educators and clinicians in the U.S. must learn from others, as well.

Limitations

Participants reported being highly satisfied with choosing nursing as a career, but that they did not feel fully ready for the professional nursing role. The most significant confidence concerns noted in this study centered on handling multiple patient assignments, calling the physician, responding to a change in patient condition, and treating a dying patient. These same results were consistent with pre-COVID-19 studies (Casey et al., 2011; Fink et al., 2008; Kovner et al., 2007; Wray, 2017; Young, 2019).

One key limitation of this study was the small, relatively homogenous sample from one institution. The majority of the students were from one predominant race and gender. The sample included some non-traditional students, reflected in the average age of 26.8 years. This average age might be somewhat higher than that of other universities which house only traditional students (18–22 years old) and could, therefore, impact the generalizability of these findings. Previous studies reported that non-traditional students perceived more readiness, and increased readiness with increasing age (Pillai, 2014).

Future research

Healthcare experts expect that the impact of COVID-19 may last until 2022 (Kissler, Tedijanto, Goldstein, Grad, & Lipsitch, 2020). More research is needed to understand the impact of COVID-19 on nursing education and transition to nursing practice. Expanded research using a larger, more diverse sample across multiple educational settings will be critical next steps to assist nurse educators and employers in better understanding how “readiness” has been impacted by the pandemic. This new knowledge can assist universities and health care agencies to continue to adapt to meet the needs of those transitioning to practice during this rapidly evolving time. While clinical confidence and readiness for practice are essential topics, more research is needed to investigate the psychological and physiological impacts of COVID-19 on nurses, nursing students, nursing preceptors, and faculty members.

Corresponding author: Eyad Musallam, PhD MSN CNE CCRN, Associate Professor, Department of Nursing, Miami University, 143 University Hall, 1601 University Blvd, Hamilton, Oxford, OH 45011, USA, Phone: +1 513 727 3275, E-mail: musalle@miamioh.edu

Research funding: None.
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interests: Authors state no conflict of interest.
Informed consent: Informed consent was obtained from all individuals included in this study.
Ethical approval: The local Institutional Review Board deemed the study exempt from review.

References

Ambrose, S. A., Bridges, M. W., DiPietro, M., Lovett, M. C., & Norman, M. K. (2010). How learning works: Seven research-based principles for smart teaching. San Francisco, CA: John Wiley & Sons.Search in Google Scholar

American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Washington, D.C.: American Association of Colleges of Nursing.Search in Google Scholar

Bowdoin, C. (2014). Thinking like a nurse and perceived readiness for professional practice: A mixed methods study. Ann Arbor, MI: Mercer University.Search in Google Scholar

Casey, K. C. (2019). Psychometric evaluation of the Casey-Fink graduate nurse experience survey. Greeley, CO: University of Northern Colorado.Search in Google Scholar

Casey, K., Fink, R., Jaynes, C., Campbell, L., Cook, P., & Wilson, V. (2011). Readiness for practice: The senior practicum experience. Journal of Nursing Education, 50(11), 646–652. https://doi.org/10.3928/01484834-20110817-03.Search in Google Scholar PubMed

Dictionary, O. E. (2018). Oxford English Dictionary. Retrived from http://oed.com.Search in Google Scholar

Duchscher, J. B., & Windey, M. (2018). Stages of transition and transition shock. Journal for Nurses in Professional Development, 34(4), 228–232. https://doi.org/10.1097/nnd.0000000000000461.Search in Google Scholar PubMed

El Haddad, M., Moxham, L., & Broadbent, M. (2017). Graduate nurse practice readiness: A conceptual understanding of an age old debate. Collegian, 24(4), 391–396. https://doi.org/10.1016/j.colegn.2016.08.004.Search in Google Scholar

Fink, R., Krugman, M., Casey, K., & Goode, C. (2008). The graduate nurse experience: Qualitative residency program outcomes. The Journal of Nursing Administration, 38(7), 341–348. https://doi.org/10.1097/01.nna.0000323943.82016.48.Search in Google Scholar PubMed

Gravina, E. W. (2017). Competency-based education and its effect on nursing education: A literature review. Teaching and Learning in Nursing, 12(2), 117–121. https://doi.org/10.1016/j.teln.2016.11.004.Search in Google Scholar

Hickerson, K. A., Taylor, L. A., & Terhaar, M. F. (2016). The preparation–practice gap: An integrative literature review. The Journal of Continuing Education in Nursing, 47(1), 17–23. https://doi.org/10.3928/00220124-20151230-06.Search in Google Scholar PubMed

Hodges, A. L., Konicki, A. J., Talley, M. H., Bordelon, C. J., Holland, A. C., & Galin, F. S. (2019). Competency-based education in transitioning nurse practitioner students from education into practice. Journal of the American Association of Nurse Practitioners, 31(11), 675–682. https://doi.org/10.1097/jxx.0000000000000327.Search in Google Scholar

Hussein, R., Everett, B., Ramjan, L. M., Hu, W., & Salamonson, Y. (2017). New graduate nurses’ experiences in a clinical specialty: A follow up study of newcomer perceptions of transitional support. BMC Nursing, 16, 42. https://doi.org/10.1186/s12912-017-0236-0.Search in Google Scholar PubMed PubMed Central

Järvinen, T., Eklöf, N., & Salminen, L. (2018). Factors related to nursing students’ readiness to enter working life–A scoping literature review. Nurse Education in Practice, 29, 191–199. https://doi.org/10.1016/j.nepr.2018.01.010.Search in Google Scholar PubMed

Kavanagh, J. M., & Szweda, C. (2017). A crisis in competency: The strategic and ethical imperative to assessing new graduate nurses’ clinical reasoning. Nursing Education Perspectives, 38(2), 57–62. https://doi.org/10.1097/01.nep.0000000000000112.Search in Google Scholar PubMed

Kissler, S. M., Tedijanto, C., Goldstein, E., Grad, Y. H., & Lipsitch, M. (2020). Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period. Science, 368(6493), 860. https://doi.org/10.1126/science.abb5793.Search in Google Scholar PubMed PubMed Central

Kovner, C. T., Brewer, C. S., Fairchild, S., Poornima, S., Kim, H., & Djukic, M. (2007). Newly licensed RNs’ characteristics, work attitudes, and intentions to work. AJN the American Journal of Nursing, 107(9), 58–70. https://doi.org/10.1097/01.naj.0000287512.31006.66.Search in Google Scholar PubMed

Leufer, T., & Cleary-Holdforth, J. (2020). Senior nursing students’ perceptions of their readiness for practice prior to final year internship: Part 2—a qualitative perspective. Dimensions of Critical Care Nursing, 39(2), 81–90. https://doi.org/10.1097/dcc.0000000000000407.Search in Google Scholar PubMed

Mirza, N., Manankil-Rankin, L., Prentice, D., Hagerman, L., & Draenos, C. (2019). Practice readiness of new nursing graduates: A concept analysis. Nurse Education in Practice, 37, 68–74. https://doi.org/10.1016/j.nepr.2019.04.009.Search in Google Scholar PubMed

Missen, K., McKenna, L., & Beauchamp, A. (2016). Registered nurses’ perceptions of new nursing graduates’ clinical competence: A systematic integrative review. Nursing and Health Sciences, 18(2), 143–153. https://doi.org/10.1111/nhs.12249.Search in Google Scholar PubMed

Morin, K. H. (2020). Nursing education after COVID‐19: Same or different? Journal of Clinical Nursing, 29(17–18), 3117–3119. https://doi.org/10.1111/jocn.15322.Search in Google Scholar PubMed

Murray, M., Sundin, D., & Cope, V. (2018). New graduate registered nurses’ knowledge of patient safety and practice: A literature review. Journal of Clinical Nursing, 27(1–2), 31–47. https://doi.org/10.1111/jocn.13785.Search in Google Scholar PubMed

NCSBN (2020). Changes in education requirements for nursing programs during COVID-19. Chicago, IL: National Council of State Boards of Nursing.Search in Google Scholar

Oblea, P. N., Berry-Caban, C., Dumayas, J. Y., Adams, A. R., & Beltran, T. A. (2019). Evaluation of clinical nurse transition program at US army hospitals. Military Medicine, 184(11–12), 914–921. https://doi.org/10.1093/milmed/usz108.Search in Google Scholar PubMed

Pillai, A. (2014). Ready, set, practice: A study of generational differences and their impact on senior baccalaureate nursing student perceived readiness to practice. Doctoral dissertations. Retrieved from ProQuest Dissertations and Theses.Search in Google Scholar

Pragholapati, A. (2020). COVID-19 impact on students. EdArXiv.10.35542/osf.io/895edSearch in Google Scholar

Romyn, D. M., Linton, N., Giblin, C., Hendrickson, B., Limacher, L. H., Murray, C., Vye-Rogers, L.… (2009). Successful transition of the new graduate nurse. International Journal of Nursing Education Scholarship, 6(1). https://doi.org/10.2202/1548-923x.1802.Search in Google Scholar PubMed

Rosseter, R. J. (2014). The impact of education on nursing practice. Washington, DC: American Association of Colleges of Nursing.Search in Google Scholar

Rush, K. L., Janke, R., Duchscher, J. E., Phillips, R., & Kaur, S. (2019). Best practices of formal new graduate transition programs: An integrative review. International Journal of Nursing Studies, 94, 139–158. https://doi.org/10.1016/j.ijnurstu.2019.02.010.Search in Google Scholar PubMed

Walker, A., Storey, K. M., Costa, B. M., & Leung, R. K. (2015). Refinement and validation of the work readiness scale for graduate nurses. Nursing Outlook, 63(6), 632–638. https://doi.org/10.1016/j.outlook.2015.06.001.Search in Google Scholar PubMed

Wolff, A. C., Pesut, B., & Regan, S. (2010). New graduate nurse practice readiness: Perspectives on the context shaping our understanding and expectations. Nurse Education Today, 30(2), 187–191. https://doi.org/10.1016/j.nedt.2009.07.011.Search in Google Scholar PubMed

Wray, M. A. (2017). Senior BSN students’ confidence, comfort, and perception of readiness for practice. Boiling Springs, NC: Gardner-Webb University.Search in Google Scholar

Young, D. (2019). Attitudes of new graduate RNs regarding their readiness for practice before and after hospital orientation. Hattiesburg, MS: Aquila. https://aquila.usm.edu/dissertations/1640.Search in Google Scholar

Received: 2020-09-16

Accepted: 2021-04-05

Published Online: 2021-04-22

Articles in the same Issue

https://doi.org/10.1515/ijnes-2020-0097

Keywords for this article

clinical education; COVID-19; NCLEX; nursing education