Newly graduated registered nurses face a barrage of physical and mental challenges in their first few years of practice, especially in the hospital setting. This article explores discrepancies between student nurse practice and professional nursing practice and the challenges that new nurses face in bridging the gap between idealistic theory and realistic practice. The author's subsequent graduate nursing education and continued practice in the field resulted in a personal evolution of practice that elicited a profound sense of appreciation for the field and a desire to share these experiences with other practicing nurses and students.
Clinical nurses are well aware of the current nursing shortage and its implications for nursing practice and patient safety. Those of us in academia are concerned about the aging nursing faculty workforce and consequently the limited capacity for enrollment into nursing programs, further worsening the shortage. However, my perspective and practice relative to the nursing shortage has evolved because of my experiences of excitement, disappointment, and determination relative to the ideal clinical practice taught in nursing school versus the reality of actual clinical practice a.. er nursing school. I suspect that those who taught me in my undergraduate program had similar experiences in their own careers, and, in addition to learning about the ideal clinical practice, I would have been grateful to also have learned about the sometimes harsh realities of clinical practice from those who served as role models and mentors to me.
My first year as a new registered nurse, I worked on a busy telemetry unit at a large hospital in New Orleans. Before accepting the position, I was warned by several nurses in the community not to work at this particular facility because "they work you like a slave." I, in my youthful optimism, told them, "Hard work has never scared me and never will." Armed with my degree and idealism about clinical practice, I accepted the position. That a.. itude lasted approximately .. months before I seriously began to question my decision to become a nurse.
Every night when I clocked out, at least 2 hours late, I felt fear that I was forge getting something important and guilt over having done little more than keep my patients breathing. My nursing practice was not even close to the way I had been taught in nursing school. One of the most difficult aspects of this job was the nurse-to-patient ratio which at times was as high as one to eight. There was scant ancillary support staff , which translated into a lack of assistance with patient transportation, phlebotomy, EKGs, and respiratory therapy. The nurse-to-patient ratio, coupled with the high expectations of the charge nurses, made the job nearly impossible for a novice nurse.
Our manager did not make our jobs any easier. Her style of management did not allow for input or collaboration about problems on the unit. She did very li.. le to assist us when we were stretched dangerously thin. Many nights I wondered why I tolerated working at a facility that did not support my needs as a new graduate. Every 2 weeks, I was reminded why I endured such poor working conditions: the paycheck. The pay I received more than adequately covered my student loans and credit card debt from nursing school.
In time, I realized I needed change, but I was very hesitant about going to another hospital because my nursing school classmates didn't have many positive comments about their places of employment either. This turning point led me to a career-altering decision: I began graduate school a.. er only .. months of practice. If asked at that time about the nursing shortage, I would have said that the working conditions at some of the nation's hospitals most certainly contributed to the shortage.
LET THE EVOLUTION BEGIN
I entered graduate school with a desire to recapture the passion for nursing that I had experienced as an undergraduate student. A.. er my experiences in my first job, I had so many questions about nursing practice. Is a one-to-eight nurse-topatient ratio safe? If I'm unhappy, how do other nurses feel? What is the impact of nurse job satisfaction on the current nursing shortage? Graduate-level nursing research became an outlet for my frustration with practice. With the help of my adviser and mentor, I narrowed down the research question for my thesis. The purpose of my study was to look at job satisfaction and career intentions of RNs working on acute care units.
In my literature review, I learned many things about nurses' job satisfaction or lack thereof. I knew that staffing pa.. erns at my first job contributed greatly to my job dissatisfaction. According to Aiken, Clarke, Sloane, Sochalski, and Silber (2..02), "Nurses in hospitals with 1:8 nurse-to-patient ratios would be 2.29 times more likely as nurses with 1:4 nurse-to-patient ratios to show high emotional exhaustion and 1.75 times more likely to be dissatisfied with their jobs" (p. 1990). My lack of experience and the responsibility for caring for this number of acutely ill patients le.. me emotionally and physically exhausted. In addition, the lack of support from the unit manager greatly contributed to my job dissatisfaction. Cline, Reilly, and Moore (200..) cite confl ict with management as a major factor in nurses leaving their jobs. Nurses reported that they "felt that managers didn't listen to their concerns or failed to act in a manner that met their needs" (p. 46). The encouragement and support of my unit manager would have decreased the high levels of stress that I experienced. However, looking back, I can only imagine how the stress of her responsibilities may have infl uenced her behavior.
Although some of the literature mirrored my personal experiences, studies that examined pay off ered confl icting findings. In a study by Cowin (2002), pay was a significant factor in job satisfaction. In this study, "more than 200 nurses used the opportunity to express their thoughts about the job satisfaction in the profession of nursing. The topic of pay was the most commonly raised theme, closely followed by a.. rition" (Cowin, 2002, p. 288). However, these nurses were dissatisfied with their pay. Pay was not one of the reasons I le.. the bedside for graduate school.
However, staffing and management were high on the list. Sumner and Townsend-Rocchiccioli (200..) found that physical and emotional stress of the job, patient acuity, staffing, perceptions of minimal respect from management, and lack of voice or autonomy are the reasons that nurses leave the profession. They state that "the tangible reward of salary is less of an issue for those who leave" (Sumner & Townsend-Rocchiccioli, 2003, p. 164). These findings more closely refl ected my experiences.
The literature review was an eye-opener for me. For the first time, I realized that I was not alone and that there were other nurses brave enough to make their voices heard about the controversial issue of job satisfaction. A.. er all, we are nurses-we care for the sick and needy without complaining. I proceeded with my data collection and analysis expecting that, despite what I noted in the literature, pay would be the most significant positive predictor of job satisfaction and career intentions in bedside nursing since this was the primary reason I tolerated the abuse as long as I did.
My research revealed a surprise that I wouldn't fully appreciate until a few years a.. er I completed my graduate studies. I found that, among the nurses in my sample, professional status, not pay, was the most significant predictor of job satisfaction and intent to remain in the current position. Professional status refers to the overall importance or significance felt about your job, both in your view and in the view of others (Stamps, 1997). When I reported these results at my thesis defense, my colleagues all seemed to understand intrinsically what I would soon learn as a nurse educator.
I completed my graduate program and accepted a position as a full-time instructor, teaching a nursing research course at one of the top nursing programs in the nation. Although I have many responsibilities as a faculty member, my colleagues are supportive and nurturing. My faculty experience is in great contrast to the experiences I described as a new graduate. Every day, I enjoy being surrounded by highly intellectual and motivated individuals who challenge me to think and perform beyond my years of experience in nursing.
I was able to make considerably more money at the bedside than I make in nursing education; however, my perspective on the importance of pay has evolved as well. I realize that, yes, professional status really does contribute more to positive job satisfaction than I previously believed. I now appreciate the importance of teaching nursing, and I enjoy the high regard I receive when others hear that I teach in a nursing program. I am the embodiment of a positive perception of professional status. Certainly, the educator role gives me a greater sense of fulfillment and satisfaction than the compensation I receive every month.
Although I enjoy teaching nursing tremendously, I have always appreciated the value of nursing practice, and I continue to practice as a bedside nurse part time during the school year and full time during the summer. As a result, I have had many more experiences in nursing and in life since my time in New Orleans. Recently, I've become interested in meeting with nurses who have le.. the nursing field. I have a hunch that this outward manifestation of job dissatisfaction is also having a considerable negative impact on the shortage.
THIS IS IDEAL
It is important that we as professionals are good role models for new nurses, whether we encounter them in our nursing programs or our clinical se.. ings. I believe that to be good role models, we must do our best to support the transition from novice to expert for our new graduates: we must educate future nurses about the best and latest evidence-based practice guidelines but must not gloss over the realities of hospital nursing. We should prepare and empower new nurses to recognize and resolve the real challenges of hospital nursing today.
In retrospect, I believe that my new graduate optimism could have be.. er served the patients I cared for had I realized the power I possessed to create muchneeded change on that unit. Therefore, I aspire to be the "idealistic reality of nursing" for the students I teach and for myself. By this I mean that I strive to teach and practice the idealism of the textbook within the contextual reality of the fl oor. It is my hope that students will be able to recognize the inevitable discrepancies and will able to begin the dialogue that will lead to the action necessary to address the challenges we face in health care today.
For the first time, I realized that I was not alone and that there were other nurses brave enough to make their voices heard about the controversial issue of job satisfaction.
To be good role models, we must do our best to support the transition from novice to expert for our new graduates: we must educate future nurses about the best and latest evidencebased practice guidelines but must not gloss over the realities of hospital nursing.
Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288, 1987-1993.
Cline, D., Reilly, C., & Moore, J. F. (2003). What's behind RN turnover? Holistic Nursing Practice, 18, 45-48.
Cowin, L. (2002). The eff ects of nurses' job satisfaction on retention: An Australian perspective. Journal of Nursing Administration, 32, 283-291.
Stamps, P. (1997). Nurses and work satisfaction: An index for measurement (2nd ed.). Chicago: Health Administration Press.
Sumner, J., & Townsend-Rocchiccioli, J. (2003). Why are nurses leaving nursing? Nursing Administration Quarterly, 27, 164-171.
Danielle E. K. Perkins, MSN, RN
Danielle E. K. Perkins, MSN, RN, is an instructor at the University of Louisiana at Lafayette and a PhD candidate at the University of Missouri at Kansas City.
Correspondence regarding this article should be directed to Danielle E. K. Perkins, MSN, RN, at email@example.com