The objectives of this study were twofold:

A tertiary analysis was to explore differences in the degree of gap perceived by new nurses and their employers in relation to specific nursing program factors. Program factors include number and type of clinical hours, number of program hours and type of program, retention rate, and first time NCLEX-RN pass rate. These factors are identified from publicly available annual report data, which is also included in current research by nursing education experts evaluating evidence provided from regulators across the country to develop evidence of what factors are used to evaluate nursing programs.

These identified gaps between education and practice are considered the missing elements necessary for practice-readiness. These elements are associated with the research of Li and Kenward (2006) to “describe the elements of nursing education, perceived adequacy of preparation for practice…” by new nurses; and to “identify the [factors] of nursing education that lead to better preparation of new nurse graduates” [7] . Li and Kenward (2006) evaluated new nurse perspectives and added perspectives of nursing education programs. Nursing education programs in New Hampshire (NH) do not have a standardized evidenced-based curriculum, and as a result, adequacy of preparation must be evaluated by employers. There is no current literature available about employer’s perceptions of readiness linked to specific elements of the education practice gap. Employers and newly licensed nurses may assist in recognizing key educational components that improve transition to practice.

With the focus on assurance of educational quality, this descriptive exploratory study surveyed new nurses’ and their employers’ perspectives related to the specific factors identified in the literature review and then compare the specific nurse/employer dyad responses. It was designed to explore the employer and new nurse responses in relation to specific factors of schools of nursing. The research study is a partial replication of Li and Kenward’s (2006) research presented in “A national survey on elements of nursing education” [7] . Li and Kenward (2006) developed the Elements of Nursing Education Study—Graduate Survey (α = 0.91; 7), which was administered to the new nurse participants. In this partial replication study, the tool was administered to NH new nurses that graduated from NH schools of nursing and took the NCLEX for NH licensure. The new nurses’ employers were also queried. The additional dimension is the gap perceived by employers. Data reviewed were identified factors that impact nursing preparedness including number of clinical hours, number of theory hours, types of programs, first time NCLEX pass rate, and retention rate. These schools of nursing factors are the dependent variables and the graduates and employer identified elements are the independent variables.

The instrument used for this research is the “Elements of Nursing Education Study—Program Survey” developed by Li and Kenward (2006) which was modified with approval from Dr. Li for this study. National Council State Boards of Nursing also provided permission to use the instrument. The instrument has been found to be reliable and valid with internal consistency ranging from 0.87 to 0.91 [7] .

Southern New Hampshire University Internal Review Board provided an expedited full approval. The lead researcher participated in “Protecting Human Research Participants” through the National Institutes of Health (NIH) Office of Extramural Research.

Participants indicate that clinical did not prepare them to administer medications to large groups of patients (40.9%) or to provide care to six or more patients (51.5%) (Appendix E). Nearly 23% of participants indicated that the clinical component of their nursing program did not prepare them to supervise care provided to others.

Most nurses felt that that they were definitely or somewhat prepared for practice, based on theoretical content (Appendix F). Approximately 20% of participants did not feel that didactic instruction prepared them to supervise care provided by other members of the health care team. A small percentage (10.6%) of participants also indicate that didactic instruction did not prepare them to delegate tasks, provide for spiritual care, or attend to a patient’s cultural needs.

All participants felt that faculties were either definitely or somewhat available to answer questions in class, answer questions in clinical settings, and assist with clinical skills. Fifty-three percent of participants answered that faculty were somewhat available to assist with classroom projects (Appendix G). Twenty-seven percent of participants responded that faculty somewhat provided the most current information in the classroom (Appendix G).

Seventy-three percent of participants indicated their current typical care assignments were just right. In contrast, 11% felt that they were not challenging enough, and 8% felt that their current client care assignments were challenging or difficult (Appendix G). Nine percent of participants indicated client care assignments were not applicable to their work situation.

Sixty-one percent of participants indicated they were involved in errors in care (Appendix H); of these, 43.9% were medication errors (Appendix I). Reportable errors included avoidable client death; two participants identified avoidable client death as errors. In the analysis of error data, it was found that six of the 43 participants (13.9%) involved with errors indicated English was not their first language. Of note, all participants who identified English as a second language were involved in errors. The majority (87.5%) of those involved in error/errors included medication error in their response. Eighteen (45%) participants were involved in at least 2 errors and nine (22.5%) participants were involved in at least 3 errors. Fifteen (37.5%) participants involved with error indicated that their clinical instruction did not prepare them to administer medications to large groups. Nineteen of 46 (41%) graduate participants of AD/Diploma programs were involved in error while only 6 (30%) BSN/DEMN participants were involved in error (Appendix J).

The employer response rate was 3%. For the majority, the employer’s responses were one level less prepared, compared to the new nurse perceptions. For example, instead of “yes, definitely prepared”, the employer chose: “yes, somewhat prepared”. This suggests the employers perceived the new nurse was less prepared than the new nurse perceived. In one instance there were two levels of separation between perceptions of preparedness between the new nurse and the employer. There was one instance in which both the new nurse and the employer agreed that the new nurse was not prepared in one area. With limited response from employers, to protect possible identification by employees, the exact statistics and numbers are not being provided currently.

Results by Program Type

For further analysis, participants were separated into two groups, those who completed BSN/DEMN programs and those who completed an AD/Diploma program for licensure. A quarter of BSN/DEMN and almost half of AD/Diploma participants (48%) indicated that clinical experiences did not prepare them to administer medications to large groups (Appendix K). Sixty percent of BSN/DEMN participants and 48% AD/Diploma participants indicated that clinical experiences did not prepare them to provide care to six or more patients. Furthermore, over a third of BSN/DEMN participants (35%) and 15% of AD/Diploma participants indicated that the didactic portion of the nursing program did not prepare them to supervise care provided by others (Appendix K).

Most participants responded that their nursing education program did prepare them to delegate tasks to other members of the healthcare team (Appendix L). However, a higher proportion of BSN/DEMN participants responded that the didactic portion of the program did not prepare them to delegate tasks to other members of the healthcare team (25% to 4%) (Appendix L). There were higher proportions of the BSN/DEMN participants that did not feel prepared through didactic instruction, to meet client cultural and spiritual needs. Many respondents indicated that didactic instruction did prepare them to use information technology (books, journals, computers videos, audio tapes, etc.) to enhance the provision of care to clients. In contrast, 15% of BSN/DEMN and 4% of AD/Diploma participants did not feel prepared to use information technology.

Calculations of Z-score based on the difference of means were conducted on these two groups. The two groups Z-score (two tailed, 95% confidence) for the clinical questions related to administering medications, is 2.779 indicating that the AD/Diploma and BSN/DEMN groups are not the same, indicating the BSN/DEMN students felt better prepared than AD/Diploma participants. The supervision of care of others related to clinical preparation Z-score of −1.92 also indicates the groups are not the same, and that the BSN/DEMN participants perceived being less prepared. The Z-scores of −2.95 for the question about delegation of tasks and −1.99 for the question about faculty answering questions during clinical activities also points to BSN/DEMN participants responding they were less prepared, and faculty were not available to answer questions during clinical activities (Appendix M).

An odds ratio was calculated on each question for each nursing program within the program type. The likelihood that a participant would say their current position was not challenging enough or too challenging in relation to their clinical preparation for supervising care in their clinical assignment was the only significance found. A student is 54% more likely to feel their clinical assignment was appropriate if they answered that they were exposed to clinical supervision skills in their training. The majority of participants felt faculty or instructors were generally available to answer questions in the classroom and clinical (Appendix G and Appendix M). Faculty assisting with clinical skills and answering questions was also positive. The lowest perceived satisfaction with faculty was the availability to assist with classroom projects for AD/Diploma (41%) nurses. Fewer BSN/DEMN participants (45%) felt faculty answered questions in clinical compared to 85% of AD/Diploma participants.

The select elements of the academic-practice gap examined suggest that the new nurse participants overall felt prepared for practice, except for a few areas. Unlike previous results of Clark and Holmes (2006), Dyess and Sherman (2009), and Oermann et al. (2010), the new nurses’ responses indicated that they felt prepared to provide care, to make clinical decisions, and to contact physicians [3] [9] [10] . The reason for these improvements is unclear; however, an emphasis on critical thinking and competency of new nurses, and interprofessional practice requirements with resulting changes to curriculum to address these competencies may have impacted this perception of preparedness. One of these changes includes the use of Assessment Technologies Institute (ATI) or other testing throughout the program. Many programs in NH use ATI or another form of testing throughout their programs. The use of these types of testing is purported to incorporate critical thinking within the testing (ATI, n.d.). However, this focus on testing may undermine examining preparedness in other areas, such as clinical knowledge and skills.

The skills that new nurses felt less prepared to performare linked to the behavioral skills found in the literature review. New nurse participants indicated feeling prepared to administer medications, but not to large groups, which agrees with the research of Kenward and Zhong (2006) [11] and Li and Kenward’s (2006) [7] . Nursing students identified that administering medications earlier in their education may improve preparedness [12] . The perception of not being prepared to take care of six or more patients or supervise care of others may be linked to the perceptions of faculty availability. This may suggest faculty that are available and teaching the information, but the students are unable to link the didactic learning to the practice setting. This may be indicative that educators are not situating the learner (connecting theory to practice), so that the student is unable to link what they learn to practice; or may be linked to clinical faculty that may be ineffective, or inexperienced in teaching. This may point to clinical faculty as a missing link in the academic-practice gap. Furthermore, this gap may be a result of clinical opportunities available through partnerships. Suggestions for improvement and further study include linking didactic and practicum, such as linking pharmacology to medication administration, ensuring didactic provides a link to practice situations [13] . Li and Kenward (2006) [7] note that their participants who felt better prepared were assigned to faculty who taught both the didactic and clinical components of the course. In addition, consideration of whether the faculty/instructor has current work experience in the clinical setting may be a factor that contributes to the academic-practice gap. Communication between didactic and clinical instructors of expectations of student outcomes linked to current practice may also be a missing link for preparedness. Overall new nurses felt that current information was provided in the classroom. However, over a quarter of participants (27.3% and 1.5%) did not always receive current information in the classroom. This was also noted by Monaghan (2015) who indicated that the theory practice gap begins within the didactic curriculum of a nursing program [14] . Kavanaugh and Szweda (2017) note the importance of faculty who are clinically current for clinical practicums [4] . The consideration of whether the didactic instructor is making the link to practice or the clinical instructor is unable to link to didactic is a question for further research. In New Hampshire, clinical nurse educators must be approved by the Board of Nursing. Requirements include a Master of Science in Nursing degree and a minimum of two years’ clinical experience in the specialty area they will be teaching/overseeing clinical. Temporary nurse educator approval for one year is extended to those matriculating in an MSN program and who have two years’ clinical experience in the specialty area they will be teaching. It may be worthwhile to conduct further research into whether experience in some clinical settings twenty years prior and only working in academia keeps the educator relevant and current.

Most new nurses identified errors within their practice, which link to the findings of Cantlay et al. (2017), Fater (2013) and Kavanagh and Szweda (2017) identified areas of curriculum weaknesses of preparation with providing safe care, or in the areas of safety and quality of care [4] [15] [16] . Makary and Daniel (2016) emphasize that medical errors are a leading cause of death in the United States [17] . Medication errors in this study were the most frequently reported error (87.5%). Cantlay, Salamanca, Golaw et al. (2017) found that new nurses may feel strongly prepared in pharmacology but unprepared in the practical knowledge of administering medications [15] . With the Institute of Medicine (IOM) “Crossing the Quality Chasm: A new health system for the 21^st Century” (2001) report; the Institute of Medicine (2003) “Health professions education: A bridge to quality”, Chapter 6, “Recommendations for reform”; and the Institute of Medicine (2011) “The future of nursing: Leading change, advancing health the need to improve education programs to reduce errors;” it is surprising this trend of errors continues [6] [18] . The call for improvements in education and practice by the National Academies of Medicine (NAM—formerly IOM) still reverberates today with these findings. A secondary concern, besides patient harm is the stress and anxiety that occurs with errors, or trying to prevent them which impacts nurses confidence and ability to provide care [19] . The high rate of errors and multiple errors recognized by these new graduates may point to the nursing program focus on teaching to successfully complete the NCLEX-RN exam compared to that which is necessary to practice safely and competently [4] . Murray, Sundin, and Cope (2018) note that the study of new nurse errors may provide academia with knowledge for curriculum improvements that can reduce errors [20] . Over a third (37.5%) of participants indicated that clinical did not prepare them to administer medications to large groups. New nurses indicated administering medications to large groups is an essential element of nursing education. It is unclear how this may be improved upon unless practice partners mentor students or new graduates. The type of clinical practicum preparation or employer expectation of new graduates may need to be evaluated. Recommendations by Beauvais, Kazer and Aronson (20107), IOM (2001), and Murray, Sundin and Cope (2018) include collaboration between academia and practice settings (work force) for program improvements [18] [20] [21] . The American Association of Colleges of Nursing indicates that even though new nurses had participated in clinical at a specific organization, that there was a lack of communication between the nursing program and the healthcare organization regarding practice readiness. Bivin (2014) argues that separation of student nurses from the healthcare organizations they worked with in the past, has increased the academic-practice gap, and the gap is potentiated by not using the nurses working in the healthcare sector as preceptors [22] . Bivin (2014) emphasizes the need for academia to partner with nurses working with patients, so that students may be better prepared for the realities of nursing practice [22] .

Almost a quarter of participants (24%) were involved in delays in treatment, and an additional 2.4% responded they were involved in avoidable client death. In the past, delays in treatment have been identified at approximately 20% [11] , and the third leading cause of death in the United States is medical error [17] . Most recent information puts yearly death and disability related to diagnostic errors closer to 795,000 [23] . Recognizing patient deterioration and emergent situations is an important aspect of nursing care. This links directly to suggestion of Herron (2017) to place nursing students in their final term in high acuity areas to provide care to patients that are unstable, and to use simulation to emulate emergency situations in patient care [24] . If high acuity clinical settings are not available, simulation of high acuity situations could be provided in lieu of a hospital high acuity setting clinical practicum. After such changes are made, further research of errors could be conducted to review results of this change.

The evaluation of the congruency between employer and student perceptions of elements of the academic-practice gap is limited due to the low response rate. The employer responses indicating that at least one and sometimes two levels lower of perceived preparedness in comparison to new nurse perception of preparedness may be linked to the research of Brown and Crookes (2006), who indicate that there is no consensus on specific skill sets among nursing educators and employers [25] . These results may suggest the need for improved dialogue between nursing educators and work force members to reduce the disconnect of what practice readiness expectations of new nurses are based on employer expectations. It may also require educating work force members about Benner’s (2001) novice to expert work and having realistic expectations of new nurse abilities [5] . These results point to the need for future research comparing new nurse and employer perceptions of readiness as well as employer and education program’s definition of “practice preparedness”.

A tertiary analysis was to explore differences in the size of the gap perceived by new nurses and their employers in relation to specific nursing program factors. The AD/Diploma program outcome responses of perceptions of preparedness were generally higher than those of the BSN/DEMN students except for administering medications to large groups (48% AD/Diploma and 25% BSN/DEMN). Interestingly, the BSN/DEMN prepared students’ perceptions of preparedness responses, and the z-scores suggest that they felt less prepared than AD/Diploma participants in providing care to six or more patients (BSN/DEMN 60% to AD/Diploma 48%); supervising care provided by others (40% to 15%); delegating tasks (25% to 2%), and legally documenting care (25% to 11%) (Appendix K). BSN/DEMN participants also answered not feeling prepared by the didactic portion of programs at higher rates than AD/Diploma participants. These include the areas of meeting client cultural needs (20% to 7%); supervising care provided by others (35% to 13%), and delegating tasks (25% to 4%) (Appendix L). The faculty or instructor availability provided similar results for both program types, except one area. The question regarding faculty “answer questions during clinical activity” responses showed less satisfaction for BSN/DEMN graduates (60%) compared to 85% AD/Diploma. Errors were reported more by BSN/DEMN participants at 65% compared to AD/Diploma at 56% (Appendix J). However, the larger cohort of AD/Diploma nurses does have twice the number of errors reported compared to BSN/DEMN nurses (Appendix J). According to Mohammad, Hossein and Abbas (2020) there are several ways to improve the didactic link to nursing practice including use of technology in the classroom, team based learning, interdisciplinary projects, and use of simulation [26] . These may be areas of consideration for nursing programs to improve the nurse education practice gap.

The number of clinical hours and the types of clinical hours varies by program in NH (Appendix N and Appendix O). The minimum number of clinical hours is 700 with the maximum of 1024. Note that there is a significant percentage of observation/experiential clinical in some programs with one program having 91 hours of observation/experiential learning that does not include hands-on patient care. According to Saifan, Devadas and Daradkeh et al. (2021) nursing students recognized that nursing clinicals should be linked to didactic and that there should be less focus on writing papers [27] . It is interesting to note that the BSN/DEMN programs on average have more clinical hours than AD/Diploma programs. Despite these higher numbers of hours, more BSN/DEMN participants than AD/Diploma participants indicated perceptions of being less prepared in several areas. This number is similar for didactic preparation with the BSN/DEMN average of 700 didactic hours and AD/Diploma 542.9, and that higher numbers of BSN/DEMN participants indicating that they were less prepared than AD/Diploma nurses.

It should be noted that overall, the students felt somewhat or prepared. This points to the need to explore the types of clinical and didactic content and perception of preparedness by specific programs. All programs represented in the study had a variety of responses to perceptions of preparedness without clusters of not being prepared by specific program. Besides reviewing responses linked to specific program hours, it is suggested that analysis based on retention rate and NCLEX first time pass rate by program be conducted. A program may have graduates with high levels of first-time pass rate, but those who also recognize elements in which they were not prepared either by clinical or didactic portions of their program. The varying success rates with first time NCLEX pass rates, linked to program retention rates and clinical hours, shows some programs have an inverse relationship between first time NCLEX pass rate and retention rates (Appendix P). Further research reviewing new nurse perceptions of preparedness linked to other program outcomes may improve understanding of nursing program success for boards of nursing. This will also provide information for suggestions for improvement of nursing programs’ clinical or didactic.