Orienting a new generation of nurses: Expectations of the millennial new graduate

doi:10.4236/ojn.2013.37062

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Open Journal of Nursing, 2013, 3, 461-466 OJN

http://dx.doi.org/10.4236/ojn.2013.37062 Published Online November 2013 (http://www.scirp.org/journal/ojn/)

OPEN ACCESS

Orienting a ne w generation of nurses: Expectations of the

millennial new graduate

Elaine M. Riegel

Department of Nursing Education, St. Joseph Medical Center with Catholic Health Initiatives (CHI), Reading, USA

Email: [email protected]

Received 30 July 2013; revised 1 September 2013; accepted 11 October 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Generational diversity provides a unique quandary

for nursing leaders and educators to enlist, orient,

and retain nurses. Millennials are the largest cohort

since the Baby Boomers and the age group from

which the nursing profession will build its future

workforce. This study examined the experiences of

the new graduate nurse of the millennial generation

as they navigate orientation in an acute care setting.

Using a Web-based survey to conduct the study al-

lowed nurses from across the country to participate

while providing easy access to the study questions.

Analysis of the data through qualitative content ana-

lysis demonstrated a dominate theme of seeking stru-

cture while expecting an individualized orientation.

The survey also revealed the importance of the pre-

ceptor and manager in the perceived success of this

generation’s transition and a need to assimilate into

the professional role of RN. Recognizing that there is

a need to promote a more individualized orientation

with improved mentoring for novice nurses and their

preceptors is evident and challenges nursing leaders

and educators to rethink current practices to retain

new nurses. Established roles within the hospital and

individual nursing units are changing and traditional

strategies for recruitment and retention no longer ap-

ply. A structured orientation can facilitate the tran-

sition from new graduate to professional nurse and

assist in the retention of qualified nurses and ulti-

mately safe patient care.

Keywords: New Graduate Nurses; Millennial Nurses;

Orientation; Generational Diversity

1. INTRODUCTION

For the first time in 30 years, th e rate of aging in th e nur-

sing workforce has slowed, largely due to the increase in

employed nurses under the age of 30 and rising enroll-

ments in schools of nursing [1]. The increase in younger

nurses entering the labor force is owed to the increase in

baccalaureate nursing programs (BSN), whose student

population is younger when compared to other nursing

education programs [1]. A higher interest in nursing and

an increase in applications to nursing schools signi-

ficantly increased as the Millennial generation entered

college age [2]. Unfortunately, in 2008 nearly 40% of

recent graduates planned to leave their current jobs wi-

thin three years; this is a significant increase from the

27.1% pre-2001 graduates [1].

This change in the demographics of nursing will im-

pact all aspects of recruitment and retention as graduate

nurses have become a considerable part of acute care

hospitals strategy to fill workplace shortages [3]. A high

turnover and an influx of new graduate nurses into the

hospital setting leads to a higher proportion of inexpe-

rienced nurses, which may not only be traumatic for the

new professional nurses, but also may impact patient sa-

fety [4].

Orientation is the introduction into the world of nur-

sing and has the potential to influence not only the

novice’s nurse’s practice but patient outcomes. The tran-

sition of gradate nurse from student to professional has

been recognized as a time of stress, role adjustment,

interpersonal conflict, and reality shock [4-7]. Although

the discussion of practice readiness is not new, there is

evidence to suggest that a new graduate’s transition in

the current healthcare environment is unique [6]. In-

creased acuity of hospital patients, reduced length of stay,

nursing shortages, and demands for technology have

placed increased stress on leaders and educators to move

new graduate nurses into practice more rapidly [6]. Also,

there is a trend to place nov ice nurses directly into h ighly

specialized areas once reserved for the expert nurse [5].

In addition, hosp ital settings often have a bureau cratic

structure with different generations of nurses following

hierarchical lines. Younger nurses reported to people of

E. M. Riegel / Open Journal of Nursing 3 (2013) 461-466

462

the next generation with the oldest generation serving in

the highest managerial positio ns. With the advent of total

quality management and continuous quality improve-

ment, a more team based approach has been adopted [8].

Shared governance has led to a flattening of this tradi-

tional hierarchy and facilitated decision making across

the generations [8]. The information age has also altered

the dependence of younger nurses on tenured staff for

expert information.

The Millennials, also referred to as Generation Y or

Net, are 88 million strong, and will comprise the majo-

rity of the workforce within the next two decades [9].

Although there have been many studies investigating

new graduate transition into practice [5,6,10-14] only a

few address this generation’s distinctive characteristics

[7,15,16]. This study examined the experience of the

Millennial generation as they engage in the social con-

text of their orientation process. The goal of the study

was to inspire managers, educators, and coaches to re-

think current practices that are designed for the masses.

2. METHOD

2.1. Design

A descriptive study was used to examine the experiences

of Millennial new graduate nurses during orientation.

The focus was to gain insight into the expectations of

this generational cohort as they enter the health care

workforce.

2.2. Participants

The nurses in this study were born between the years

1980-1989, and graduated from a nursing program wi-

thin three years of the study. They were employed in

acute care and had started or had recently finished their

orientation process within the clinical setting. Of the

seventeen participants, 47% (n = 8) worked in critical

care, 35% (n = 6) medical/surgical, 12% (n = 2) in a

pediatric setting and 6% (n = 1) in ECU; 16 of the par-

ticipants were female and 1 was male. Their nursing

educational background included diploma (n = 4), as-

sociate degree (n = 1) and baccalaureate degree (n = 12).

In order to recruit participants, nurse educators wi-

thin the Catholic Health Initiatives (CHI) health system

and Kutztown University were provided, via email,

information about the research proposal. The nurse

educators were asked to seek out new graduate nurses

via “word of mouth” who would meet the age criteria

and provide an email address to contact the researcher

if interested in participating in the survey. The new

graduate nurses who contacted the researcher by email

only needed to provide a return email address and were

not asked to share any additional information. They

were then sent a link via email that would be used to

connect them to the Web-based survey. If they agreed to

share their experiences, instructions were provided in

the introduction of the survey explaining their consent

and information to contact the researcher, the research-

er ’s advisor and IRB representative with any questions.

No potential risks were identified by participating in

this research survey, and none of the nurses were

compensated for their time. During completion of the

survey, if they wished to d iscontinue th eir particip ation,

they needed only click out of the screen and no infor-

mation would be saved

2.3. Instrumentation

Using an online tool and email for communication as-

sured confidentiality and permitted collection of data

using technology familiar to this cohort. The study re-

quested demographic data and proposed several open

ended questions which required narrative responses. All

questions used in the study were validated by a research

advisor in the role of subject matter expert.

Questions included: “Describe your expectations of

how nursing orientation wou ld be conducted”, “Describe

ways in which your orientation met these expectations”,

“Describe ways in which your orientation did not meet

these expectations”, “What were your experiences of

being a new graduate nurse in orientation”, “Why did

you select nursing as a profession?”, “How did your ori-

entation impact your thoughts about nursing as a pro-

fession?” and “If you could give advice to another new

graduate nurse entering their orien tation, wh at w ould you

tell them?”

2.4. Data Collection

The Web-based survey was available to research parti-

cipants for three months and was closed when participant

responses met saturation.

Changes brought by the use of computer technology

have allowed the use of asynchronous communication

such as email and online surveys to recruit and conduct

research. The Internet has been used by other disciplines

for both qualitative and quantitative data collection, as it

allows for a wider geographical sampling, while decrea-

sing the costs associated with data collection and time

taken to collect the data [17,18]. Broader sample collec-

tion, easier recruitment of particip ants through the use of

message boards, email lists and chat-rooms and speed of

responses are several advantages of using the Internet for

research [17-20].

2.5. Data Analysis

Colaizzi’s [21] framework was used to guide the analysis

of the participant’s responses. Using this outline involved

reading and rereading the responses, extracting signifi-

E. M. Riegel / Open Journal of Nursing 3 (2013) 461-466

463

cant statements and exposing meanings. Information was

clustered into themes and then integrated into an exhau-

stive description of the phenomenon [22]. As this frame-

work also requires returning to the participants to vali-

date that the data represents their experiences [23], the

participants were sent a follow-up email describing the

themes extracted from the survey responses requesting

any additional input.

3. RESULTS

The responses generated by the new graduate nurses

reflected the theme of seeking structure including the

expectation of an individualized orientation and open

communication with preceptors and managers. A sub

theme of role transition also surfaced as the new nurses

expressed the need to assimilate into the unit’s culture.

3.1. Seeking Structure

As the new graduate nurses described their experiences

during orientation, the need for structure was a theme

voiced by all of the participants. Within this topic of

structure, the respondents revealed a need for consistency,

organization and open communication. The new nurses

entered their employment with a plan of how their ori-

entation would flow. From review of policy and proce-

dures, to actual task management in their unit, the nurses

expected moving from simple to more complex tasks.

One survey participant described the structure of their

orientation as “the framework for me to build upon to

become a more confident nurse”.

Building on a foundation of classes then clinical, new

graduates anticip ated their orientation to mimic the stru c-

ture of their school environment. Several nurses describ-

ed an expectation of orientation being similar to nursing

school practicum with a mix of classes and on the unit

training. One nurses commented that she “wanted more

hands on learning, skills training or simulation”.

Not having exposure to the hospital environment other

than in the clinical setting as a student, the new graduates

did not anticipate the difficulties they would encounter

practicing as an RN. Having a faculty nursing instructor

allowed the student a consistent preceptor and provided

structure dur ing their clinical experiences. As a new RN,

the nurses needed to find this structure from the ranks of

their co-workers. A supportive and consistent preceptor

increased the new nurse’s confidence and aided in the

new nurses abilities to func tion on th e unit. Having g oals

set by their preceptor with cons tant feedback allowed the

new nurse to feel prepared to practice on their own when

orientation was complete.

Much of the disappointment listed by these novice

nurses was related to inconsistent preceptors and lack of

communication with their managers. There was a need to

develop a routine and receive feedback on their perfor-

mance. Many described feeling “overwhelmed” by the

diverse routines of each new preceptor. Several described

preceptors who “did not care” and were “pessimistic

about their job” and others who would “not follow pro-

per policy and procedure”. Also, having a preceptor fun-

ction as the coach and charge nurse did not allow the

preceptor to “devote herself to teaching”, since she also

had the role of managing an entire unit. This lack o f role

clarity and adjusting to different routines and persona-

lities made orientation more confusing and complex. In-

consistent preceptors, to aid in their learning experience,

were a frustration voiced by many of the new graduates.

Defining roles and responsibilities was another struc-

ture based theme expressed by the Millennial new gra-

duates. They had difficulty knowing how to practice in

this new role, and thus how to make critical thinking

decisions. As students, they had the instructor to aid in

any decision making, but as new graduates they were

insecure in their judgment skills and expected a com-

prehensive classification of their roles and responsi-

bilities. Communication was lacking, as the nurses were

unsure how to make decisions in practice, and unclear

where to find the information.

Within the theme of seeking structure the new nurses

also expected an individualized orientation with a focus

on their specific specialty. Orientees would be allowed to

“work at their own pace” and “not feel rushed”. Nume-

rous responses from the survey mentioned specific time

frames that nurses were given to complete their orien-

tation instead of developing an orientation program

based on their individual needs. Also, needing “time to

sit down and discuss what was needed from our orien-

tation with the preceptor and manager”. Open communi-

cation between the manager, preceptor and new em-

ployee aided in individualizing the orientation for the

new hire and minimized the expectation of orientation

being set by a specific time frame. As many of the survey

respondents were employed in an ICU setting, the anti-

cipation of classes specific to their learning needs and

more time to orient in a specialty area was expressed.

3.2. Needing to Assimilate

The transition from student to RN was another theme

that emerged from the survey responses. Many of the

respondents wrote about adjusting to personalities and

finding their niche within the social ladder of the unit.

The graduates felt overwhelmed and anxious when faced

with the realities of their job and looked to their

colleagues for suppo rt and mentorship. Bo th positive and

negative experiences were voiced by the newcomers as

they navigated through the territory of the incumbent

nurses:

E. M. Riegel / Open Journal of Nursing 3 (2013) 461-466

464

“I learned a lot by asking my experienced co-workers

questions. Was definitely a scary experience, especially

not knowing who could be trusted. A couple older nurses

were very mean and did not treat young, new nurses

nicely.

Most of the nurses were supportive and willing to

teach, but I felt as if some of the more ‘senior’ nurses

would try to belittle the graduate nurses. It took a while

to earn the respect of some nurses.”

Participants also commented on the strong bonds they

had formed with other new graduates and their precep-

tors. These relationships enabled the new graduate to

connect to their unit and have a more successful tran-

sition into the culture. Several nurses expressed how the

support they received from their coworkers impacted the

success of transitioning from student to professional

nurse. These relationships allowed them to form bonds,

develop trust and adjust to the difficult realities of the

job.

Value conflict and disenchantment with their new role

as an RN were also expressed by the new graduates.

Many entered nursing with an id ealistic vision of the role

and must compare this view to the actuality of the occu-

pation. Graduates voiced their inner conflict with dif-

ficulties maintaining compassion and inability to control

patient outcomes.

4. DISCUSSION

The need for structure, guidance and extensive orien-

tation with formalized clinical coaching and feedback

has been highly valued by this generation [24] and was a

dominate theme expressed by these research participants.

Millennials have been accustomed to nurturing and con-

tinuous feedback from their parents, sports team coaches,

and teachers and have similar expectations in the work-

place [16], “This generation is able to integrate large

amounts of diverse sources of information and have little

tolerance for inefficiency or ineffectiveness” [8]. Lavoie-

Tremblay, M., Paquet, M., Marchionni, C., & Drevniok,

U. [25] found that this generation of nurses sees coa-

ching as a vital need; and coaching involves more than

guidance during the first days or weeks, but a long term

commitment. Nursing leadersh ip must also be visible and

transparent to this gen eration [6].

Preceptor matching is also a high priority to this

generation, and there is evidence that preceptors play a

significant role in the new graduate’s experience [10].

Almada, P., Carafoli, K., Flattery, J., French, D., &

Mcnamara, M. [10] used Benner’s model to guide a pre-

ceptor program in their institution which demonstrated

improved retention of new graduate nurses. “According

to Benner, new graduate nurses require the opportunity

to practice and ask unlimited questions in a safe and

supportive environment for an extended period of time”

[11] Lamp, K., Stratton, K., & Welsh, J. [7] found that in

addition to having consistent preceptors, it may be easier

for the new graduate of this generation to learn from a

preceptor with a similar communication style.

The desire for an individualized orientation was ex-

pressed frequently by the novice nurses in this research

study. Growing up in a global economy, this generation

expects multiple options and the ability to have custo-

mized alternatives [8]. They have attended public schools

and universities where the Individualized Education

Program is federally mandated to provide customized

education plans for children with learning disabilities

[26]. When they enter the workforce, the expectation of

personalized orientation program to match their needs

continues. In fact, new graduates of this generation with

opportunities to have input into their own orientation

have expressed an increased interest in their professional

development [7]. Scott, E., Keeher, M., & Swanson, M.

[14] found that new graduates, in general, who expe-

rienced a longer orientation that met all of their needs,

were more satisfied with their jobs.

The transition from student to nurse is experienced by

all new graduate nurses and was a strong focus in many

of the responses in this research study. It influenced both

immediate and long-term outcomes in the process of

becoming a nurse and orientation mark the most crucial

part of the transition [12]. It is been documented by

many studies that the first three months of employment

as a new graduate nurse represents the most stressful

time in a nurse’s career [12]. Differences between work

and school in terms of ideology and pragmatics are

quickly realized, and Delaney [12] discovered that work

presented different outcome objectives for the new

nurses when compared to school. Duchsher [27] revealed

feelings of disillusion with what the new graduate ex-

pected in their role as a professional nurse as compared

to the actuality of practice. Prior to employment as a

nurse, new graduates were found to be unprepared for

and had limited awareness of what the profession of

nursing entailed and had been shielded, as students, from

the full breadth of the role [13]. Olson [16] documented

in her research that the millen nial novice nurse conveyed

that the unfamiliarity with the acute care facility was a

barrier to incorporate new knowledge, and as nursing

students they did not have enough hours spent in an

acute care facility. All these studies speak to the reality

shock man y new nurses encounter as they feel overwh elm-

ed by their new ro le [11].

Many research studies connect conflict in the work-

place with retention of nurses. During transition into

practice, the achievement of some degree of attunement

with colleagues was an important part of being able to

function in the clinical setting [28]. The nurses in this

study connected their ability to function safely on the

clinical unit with the opportunity to seek assistance and

E. M. Riegel / Open Journal of Nursing 3 (2013) 461-466

465

ask questions. Zinsmeister & Schafer [29] completed re-

search on the transition into nurses first year of practice

and noted that participants indicated that a supportive

work environment contributed positively to their evo-

lution into the professional role of a nurse. New nurses

look to their colleagues for advice and questions about

practice; Dyess and Sherman [6] reported many instances

when new graduates received contradictory information

with too many opinions and no confirmed answers.

Millennials’ especially appreciate a team based collabo-

rative approach to work, since their educational expe-

riences were based on interdependence and networking

[30]. The new graduate of this generational cohort placed

significant value on relationships and “finding their

voice” [16].

The majority of the research participants in this study

oriented in a specialty nursing unit and anticipated edu-

cation related to patient management in their field. Dyes

and Sherman [6] described new graduates in the high

acuity specialty areas as needing not only extensive edu-

cation related to technology and disease management but

also emotional support related to intense patient situa-

tions that occur in these types of un its.

5. CONCLUSIONS

New graduates currently comprise greater than 10% of

acute care facilities nursing staff [16], and Millenials will

be a great part of this statistic. The costs associated with

training and coaching new graduates will be lost if

retention rates remain low. The goal of this study was to

understand the lived experiences of the millennial new

graduate nurse, while appreciating the diverse differences in

their expectations of training and education. “One size

fits all” orientation programs will not provide the edu-

cation needed by this generation and will contribute to

turnover. Managers and educators need to rethink current

practices and promote a team based environment while

providing open communication and consistent feedback.

Preceptor training and mentoring also needs to be a

priority. Visibility of the manager and coach, and the

influence of the unit’s culture are crucial to the success

of the new graduates first year [31].

Transition into practice, through residency programs,

has been endorsed by the Institute of Medicine’s Future

of Nursing “Campaign for Action” [32], and appears to

address the many of the issues confronting this new ge-

neration of nurses. Residency programs provide the struc-

ture and emotional support desired by this cohort while

preparing new graduates to practice in a complex envi-

ronment.

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