Experiences and learning during a graduate

nurse program: an examination using a focus

group approach
Lisa G. McKenna
a,
*, Campbell Green
b,1
a
School of Nursing, Monash University, Peninsula Campus, McMahons Road, Frankston, Vic. 3199,
Australia
b
Peninsula Private Hospital, Frankston, Vic. 3199, Australia
Accepted 20 January 2004
Summary The graduate nurse year requires individuals to make a huge transition
from university student to registered nurse as part of the health care workforce.
New graduates experience steep learning curves throughout the rst year of
professional practice. This study sought to explore experiences and learning
occurring throughout the graduate nurse program for a group of seven new nurse
graduates. Focus group interviews were conducted at six months and 12 months into
the program using the same set of guiding questions. The rst interview highlighted
that graduates early in the graduate year were internalised, concentrating on their
own survival in managing workloads, facing practice realities and coming to terms
with themselves as nurses. Learning was primarily about survival strategies and
performing tasks. By the second interview, graduates were much less focussed on
themselves. They understood their place in the health care team, had gained
condence in their relationships, and were showing concern for the next graduates
arriving. Learning at this stage involved more higher order skills, including critical
thinking.

c
2004 Elsevier Ltd. All rights reserved.
KEYWORDS
Graduate nurse;
Focus group;
Practice realities;
Learning;
Experiences;
Identity development
Introduction
The graduate nurse year sees individuals making the
transition from university student to registered
nurse as part of an institutions workforce. This
transition involves signicant personal and profes-
sional growth. Experiences of new graduates can be
fear-provoking or satisfying depending on a range of
factors including the degree to which the individual
is provided with ongoing support and encourage-
ment. Many nurses actually leave the profession in
the rst 12 months following graduation (Com-
monwealth of Australia, 2002; Owens et al., 2001).
Graduate nurse programs have been developed by
many Australian hospitals to assist with transition
processes by providing supported environments and
*
Corresponding author. Tel.: +61-3-9904-4352; fax: +61-3-
9904-4655.
E-mail addresses: lisa.mckenna@med.monash.edu.au,
cgreen@benchmarkhealthcare.com.au.
1
Tel.: +61-3-9788-3466; fax: +61-3-9789-4124.
1471-5953/$ - see front matter

c
2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nepr.2004.01.004
Nurse Education in Practice (2004) 4, 258263
www.elsevierhealth.com/journals/nepr
Nurse
Education
in Practice
educational opportunities but vary in delivery
(Commonwealth of Australia, 2002).
Literature review
A signicant body of literature exists around the
new graduate nurse. Some of this has surrounded
concern about the preparation of new graduates
to function effectively in the clinical environ-
ment, including possessing undeveloped critical
thinking and problem solving skills (del Bueno,
1994). Duchscher (2001) interviewed nurses fol-
lowing their rst six months as nurses. She sug-
gested that new graduates apply a linear model
of thinking to their practice and focus on com-
pleting tasks without thinking about the rationale
for their actions. Graduates have a strong de-
pendency on experienced colleagues and do not
establish the fundamental independence that
gives them a sense of themselves as professionals
(Duchscher, 2001).
New graduate role
The move into the role of new graduate nurse has
been described as being one that evokes signi-
cant stress and can be overwhelming (Ellerton and
Gregor, 2003; Kelly, 1998; Thomka, 2001). Gerrish
(2000) suggests that stress is contributed to with
increasing accountability for practice, ward and
patient management responsibilities and neces-
sary prociency of clinical skills. This may be
compounded by applying knowledge from under-
graduate courses into patient care along with ac-
quisition of new skills (Oermann and Garvin,
2002). As a consequence, reality shock is a com-
mon occurrence for new graduates (Common-
wealth of Australia, 2002; Winter-Collins and
McDaniel, 2000). Chang and Hancock (2003) found
that graduates stress changed from role ambigu-
ity early, to role overload later in the graduate
year. Through the period of being new graduates,
nurses require ongoing support and guidance to
ensure continued development (Owens et al.,
2001; Pigott, 2001). Furthermore, if there are
insufcient role models, graduates will endeavour
to t in and get tasks completed rather than
practising their ideal conception of nursing (Wil-
son and Startup, 1991).
Research indicates that often the process of
socialization for new graduates occurs haphazardly
(Gerrish, 2000; Thomka, 2001) and lacks consis-
tency (Thomka, 2001). A study conducted by
Thomka (2001) found that new graduates expected
that they would be accepted and supported in the
clinical environment, however, many found that
their experiences did not meet their expectations.
Some graduates reported being criticized openly
and in front of others. Furthermore, many reported
little consistency in how they were assisted to be-
come socialized into the environment or their de-
velopment. Holland (1999) suggests it is unfair to
expect student nurses to articulate their learning
into accountable practice immediately upon reg-
istration, and that the profession needs to take into
account the complexity of their new role as quali-
ed nurses. Kelly (1998) examined how a group of
new graduates adapted to the real world ex-
trapolating six stages experienced: vulnerability,
getting through the day, coping with moral dis-
tress, alienation from self, coping with lost
ideals, and integration of new professional self-
concept (p. 1137).
Graduate nurse programs
Many health care institutions offer graduate nurse
programs to assist the process of transition from
student to professional nurse. According to Clare
et al. (1996), whilst graduates have met compe-
tency requirements of their undergraduate
courses, they require orientation to the specic
clinical context into which they are entering.
Graduate nurse programs assist with development
of clinical skills, increase familiarity with the
employing institution, as well as increasing self-
condence. Furthermore, these programs assist
the graduate to adapt to the work environment
working as part of the team (Pigott, 2001). How-
ever, these programs are not compulsory and vary
greatly in content and support (Commonwealth of
Australia, 2002).
Methodology
This paper reports on a small qualitative study that
was designed to provide understanding around the
experiences of new graduate nurses in their rst
year of professional practice. Specically, it sought
to identify sources and types of learning and chal-
lenges facing new graduates, as well as identify
people and resources that are benecial to new
graduates. It was anticipated that ndings from the
study could assist with informing development of
future graduate nurse programs, assisting to ensure
that graduates needs are addressed at an optimal
level.
Experiences and learning during a graduate nurse program 259
Focus groups were chosen as an appropriate data
collection tool for this study as they bring together
people with some similarities to allow the emer-
gence and investigation of trends (Krueger, 1994),
identication of key issues, insights into experi-
ences and perspectives (Jackson, 1998). This ap-
proach allowed for issues arising to be explored
among the group. In order to identify if graduates
experiences changed during the program, it was
decided to interview new graduates at two stages
during their program, that is, at six months into the
program, and again at the end.
The study sample was chosen using purposive
sampling from a group of nurses almost six months
into their graduate nurse program across one group
of hospitals. After an introduction to the project,
potential participants were invited to participate
and provided with written documentation about
the study, including their right to withdraw at any
time. A total of seven individuals consented to
participate. This number was considered appro-
priate for effective focus groups, as 610 people is
considered optimal (Krueger, 1994).
Formal ethical clearance was given by the rele-
vant university ethics committee, and written ap-
proval given by the Director of Nursing at the
hospital as no formal ethics committee was in
place there. Strategies were put in place to ensure
condentiality of individuals contributions. Par-
ticipants were provided with pseudonyms to pro-
tect their identities in the transcribed interviews.
The second researcher, who also conducted the
graduate program, was not involved in the focus
groups, and worked only with the transcripts with
pseudonyms. In addition, participants were re-
minded prior to the commencement of each focus
group about the need to protect each others
condentiality outside of the group.
A mutually agreeable time was chosen for each
of the focus groups within allocated study days in
the graduate nurse program. A series of questions
was developed, guided by available literature and
personal experience, to guide the focus groups
(see Appendix). These questions were the same for
both focus group sessions which allowed for some
comparisons across time to be made. Focus groups
were audio taped, transcribed verbatim and con-
tent analysis performed. Transcripts were initially
read and signicant statements were removed
independently by both researchers. From these,
meanings were developed and then clustered into
themes according to frequency and intensity
(Neuman, 1997). The independent ndings were
then compared by both researchers, and nally
with the original transcripts for validation of the
ndings.
Findings
From the two focus group interviews it became
clear to the researchers that experiences and
learning of participants leading up to each inter-
view were signicantly different. In the rst six
months of the graduate program, participants
appeared focussed on internal issues surrounding
their clinical practice, personal identity and cop-
ing strategies. Despite questioning about their
learning, the focus was largely on survival and it
became clear that learning had been limited to
this point. By the second interview participants
focuses had externalised. They displayed the de-
velopment of focus on others, including patients,
the health care team and on extending their
learning.
Focus group one: focussing on self
Working on clinical skills
A focus on the performance of technical skills
emerged in the rst focus group. Being expected to
perform clinical skills for the rst time as a regis-
tered nurse was described as fear-provoking and an
area focused on for mastery during the rst six
months, eventually eliciting a sense of satisfaction
as suggested by Sam:
Ive nally come to terms with IVs and antibiotics, ush-
ing things and knowing when things are appropriate to
mix and when theyre not appropriate to mix and that
was my biggest fear. . . most of the time I feel comfort-
able with that. (Sam)
The need to master clinical skills included some
skills that had not been taught in university courses
but were expected in the clinical setting also
formed part of the learning experience, an issue
raised by Margaret:
. . . things like. . . doing male catheterisations we werent
taught. Well its really good to be able to go at the end
of the day and say I did that. . . (Margaret)
Learning for graduates up to this stage heavily
involved learning to develop routines and manage
allocated workloads. This at times meant not pro-
viding time for addressing patients needs for in-
formation. Sam and Paula both described being
aware of this:
Ive got a routine happening but also time managements
been an issue really because youve got to be prepared
and ready to go so I think thats the biggest thing Ive
learnt since Ive been here. (Sam)
Sometimes you feel rude. You just want to run in the
room and do their obs and just run out again. And some
260 McKenna and Green
of them just want to talk or ask you a question and you
just dont have time to do or you might give up the time
cause you think I will stay here and talk to them and then
you just fall behind even more. Thats always a hard bal-
ancing act. (Paula)
Overall, learning was seen by participants to be
different from that which they had undertaken at
university. In this setting learning was more prac-
tice-oriented and related to repeated skills prac-
tice as highlighted by Rachel:
Its a different type of learning. I began with the antibiot-
ics what to mix with and all that so I became very good
with all that. (Rachel)
Facing realities of practice
Realities of practice emerged in many contexts in
the rst focus group interview. Participants ex-
pressed that they were just starting to understand
what nursing was actually about something their
university courses had not provided. For example,
Paula suggested:
Ive learnt what it really is to be a nurse. I dont think uni
ever prepared me for it, just actually working and now
Ive got a better idea of what Im expected to do. I never
knew what it was like. (Paula)
Learning intricacies of the particular practice
setting also emerged as participants sought to un-
derstand their employing institution and enhance
their survival within it. This needed revisiting
whenever a new clinical rotation occurred or, as
indicated by Rachel, on moving from night shift to
day shift:
My biggest fear was who to go to and who to contact and
because I started with night duty for three months and
Ive just gone onto days and lates for the last three. . .
Im just relearning everything. (Rachel)
Personal identity
Interestingly, at this stage participants were grap-
pling with the notion that they were in fact nurses.
Participants saw themselves as graduates rst, and
as nurses second. This perspective provided them
with security in being able to justify any lack of
knowledge or skill in the clinical area, as high-
lighted by Paula, Sam and Rachel:
Its your year to ask questions and be dumb and. . . (Paula)
Make mistakes. Its all part of learning, all part of learn-
ing. . . cause they know youre a graduate. You feel a bit
safer. (Sam)
After studying for three years, it took me a while to get
over the fact that Im not a student anymore, Im a grad.
I think it will take me a while to get over the fact that
next year I wont be a grad anymore. (Rachel)
Coping mechanisms
There was evidence that participants up to this
interview had developed coping strategies to assist
their survival in their workplaces. Caroline spoke of
how she managed knowledge decits when patients
asked her questions:
Because they ask you about their procedure. You eventu-
ally get to know a bit about it to inform patients. Youre
blufng your way through it, being quiet. (Caroline)
Focus group two: refocussing on the bigger
picture
The second focus group interview revealed signi-
cant changes in the graduates approaches to
themselves and their places within the institution.
Unlike the rst interview, focus was externalised
towards patients, the health care team and ex-
tension of learning. Participants emphasis had
shifted to higher order thinking issues and self-
actualisation.
Focussing on patient care
The development of nursepatient relationships
was a signicant area of which participants were
much more aware. They described being able to
focus on patients and their conditions and to apply
their assessment skills, rather than worry about
their own performance. For example, Margaret
indicated that:
Youbecomemorecomfortablewith situations too. Youcan
walk into a roomandnot have toworry amI doing this right.
You use your assessment skills and say well this is whats
wrong with this patient and Im going to do something
about it and not have to think am I doing the right thing
for this patient. (Margaret)
Increased control over technical aspects of work
resulted in increased awareness of patients needs.
Greater emphasis was seen to be becoming placed
on holistic care, including psychological needs of
patients, as described by Margaret:
Because youve got your mechanical things under wrap
doesnt take two hours to do a dressing. Youve got more
time to sit down and discuss the psychological issues with
patients, nd out whats happening for that patient. . .
You learn to talk while you are doing things. (Margaret)
Personal and professional development
This interview also revealed a shift in participants
awareness of their own personal and professional
development. It was evident that participants at
this point recognised that they were not sole prac-
titioners but that they were part of a team. Their
perceptions of themselves were higher than earlier,
and they felt much less subordinate than in the
Experiences and learning during a graduate nurse program 261
earlier interview. There was an indication of moving
away from seeing themselves as graduates and now
as nurses. Caroline identied making such as shift:
Its more about team work now. You see yourselves as al-
most an equal. (Caroline)
The ability to use their assertiveness was an-
other aspect of professional growth that became
evident at this stage. Where in the rst interview
participants felt that they needed to manage situ-
ations on their own for fear of failure, they now
felt comfortable enough to ask for assistance when
they recognised reaching their limitations, as
Christy outlined:
One of the things that Ive found is to be able to be asser-
tive and say to people look I cant handle this. Youre not
going to do this to me and Im not going to take this pa-
tient. . . You get more condence in saying to people look I
really need a hand. Youve got to come and help me now
whereas before it was, I dont know whether I should. I
dont really want to ask cause its like Im failing. . .
(Christy)
One of the signicant areas that emerged at this
stage was the growth in professional esteem and
realising they themselves may have valuable
knowledge and experience to share with others.
This indicated a sense of acceptance into the pro-
fessional nursing context. Sam highlighted this
through an example of herself being asked ques-
tions by other nurses:
. . .you nd people come and ask you questions what do
you think I should do with this?. . . Whether or not you
can give them the answers or nots another thing but they
still come and ask you whereas six months ago they
wouldnt have cause you looked like you were ounder-
ing. (Sam)
It also emerged that participants recognised
their value in developing future nurses, especially
the roles that they might play in assisting the
transition of new graduates to the workplace.
Margaret spoke about how her own experiences
may assist the new group of graduates:
I think you can empathise a lot more with them because
you think gee I was there twelve months ago. I know ex-
actly how you feel and makes you want to help them be-
cause you dont want them to go through the same
stresses that you went through bashing your head against
a brick wall all the time. (Margaret)
Discussion
This study revealed differences in learning and ex-
periences at two randomly selected points in a
graduate year. These relate only to one group of new
graduates and their experiences and as such cannot
be readily generalisedtoall graduates, however, the
ndings do add support to the existing body of
knowledge around new nurse graduates and their
experiences. The outcomes suggest that there are
developmental stages through which new graduates
progress. Similar to ndings of previous studies
(Kelly, 1998; Thomka, 2001), the graduates in this
study experienced stress and fear early in their pro-
gram. In these early stages, graduates concerns are
around their performance with clinical skills, facing
realities of practice and coping. There is support for
the work of Duchscher (2001) in that graduates ap-
pear to focus on task completion without really
considering rationale. By thesecondhalf of theyear,
theyhadbeguntobecomemoreopenandbetter able
to acknowledge external inuences through greater
application of higher order processes such as critical
thinking. Similar to ndings by Duchscher (2001)
nurses at six months following graduation focused on
themselves, rather than on patients.
The new graduates in the study group perceived
themselves as a sub-set of nursing identifying as
graduates rst, and as nurses second. They were
able to seek support for any deciencies in skill or
knowledge in doing this. The development of pro-
fessional identity for new graduates does appear to
take some time to develop and supports Chang and
Hancocks (2003) nding that new graduates early
in the year experience role ambiguity. This current
group questioned their role and found it difcult to
identify early with nursing professionals.
This study involved only two periods of time
chosen at random by the researchers. Other studies
have employed similar approaches at three months
(Ellerton and Gregor, 2003) and at six months
(Duchscher, 2001) into graduate years. Further
studies on a larger scale, and employing different
methodology, are indicated to articulate greater
detail about what new graduates experience and to
assist with identifying specic types of support
required. Understanding the graduate nurse be-
yond the six month period is more limited and
would benet from further research. Increased
understanding of what new graduates experience
will allow for more appropriate support structures
to be developed and tailoring of graduate programs
towards the changing needs of new graduates by
nurse educators.
Conclusion
The graduate year is one of great development but
can provoke stress and uncertainty in new graduate
262 McKenna and Green
nurses. The individual must adjust from university
to the workplace, in so making a transition from
the role of student to registered nurse. This in-
volves a period of extensive growth, both profes-
sionally and personally. Ongoing support is required
to ease the transition. This focus group study has
identied different types of learning and experi-
ences that occur during the graduate year, along
with types of support that may assist with the
transitional processes taking place.
Acknowledgements
The authors thank the nurses who participated in
the focus groups and allowed us to explore personal
aspects relating to experiences and learning during
their graduate nurse program.
Appendix A
References
Chang E., Hancock, K., 2003. Rolestress androle ambiguity in new
nursing graduates. Nursing and Health Sciences 5, 155163.
Clare J., Longson D., Glover P., Schubert S., Hofmeyer,
A., 1996. From university student to registered nurse:
the perennial enigma. Contemporary Nurse 5, 169176.
Commonwealth of Australia, 2002. The Patient Profession:
Time for Action, Report on the Inquiry into Nursing.
Available from <www.aph.gov.au/senate/committee/
clac_ctte/nursing/report/contents.htm> [Retrived 20/6/
03].
del Bueno, D.J., 1994. Why cant new grads think like nurses?
Nurse Educator 19, 911.
Duchscher, J.E.B., 2001. Out in the real world: newly graduated
nurses in acute care speak out. Journal of Nursing Adminis-
tration 31, 426429.
Ellerton M., Gregor, F., 2003. A study of transition: the new
nurse graduate at 3 months. Journal of Continuing Education
in Nursing 34, 103107.
Gerrish, K., 2000. Still fumbling along? A comparative study of
the newly qualied nurses perception of the transition from
student to qualied nurse. Journal of Advanced Nursing 32,
473480.
Holland, K., 1999. A journey to becoming: the student nurse in
transition. Journal of Advanced Nursing 29, 229236.
Jackson, P., 1998. Focus group interviews as a methodology.
Nurse Researcher 6, 7284.
Kelly, B., 1998. Preserving moral integrity: a follow-up study
with new graduate nurses. Journal of Advanced Nursing 28,
11341145.
Krueger, R.A., 1994. Focus Groups: A Practical Guide for Applied
Research. Sage, California.
Neuman, W.L., 1997. Social Research Methods: Qualita-
tive and Quantitative Approaches. Allyn & Bacon,
Boston.
Oermann, M.H., Garvin, M.F., 2002. Stresses and challenges for
new graduates in hospitals. Nurse Education Today.
Doi:10.1054/nedt.2001.0695.
Owens D.L., Turjanica M.A., Scanion M.W., Sandhusen A.E.,
Williamson M., Hebert C., Facteau, L., 2001. New graduate
RN internship program: a collaborative approach for system-
wide integration. Journal for Nurses in Staff Development 17,
144150.
Pigott, H., 2001. Facing reality: the transition from
student to graduate nurse. Australian Nursing Journal
8, 2426.
Thomka, L.A., 2001. Graduate nurses experiences of interac-
tions with professional nursing staff during transition to the
professional role. The Journal of Continuing Education in
Nursing 32, 1519.
Wilson A., Startup, R., 1991. Nurse socialization: issues
and problems. Journal of Advanced Nursing 16,
14781486.
Winter-Collins A., McDaniel, A., 2000. Sense of belonging and
new graduate job satisfaction. Journal of Nurses in Staff
Development 16, 103111.
Guiding questions for both focus groups
How would you describe your learning over the
past three months?
What have been the major areas of learning in
this time?
What have been the sources of that learning?
What have been the most satisfying elements for
you to date?
What have been the most challenging or difcult
aspects to date?
What types of people have been the most
inuential during this time?
How do you perceive yourself as a registered
nurse?
Experiences and learning during a graduate nurse program 263