Using GOOGLE Scholar, you must choose a scholarly journal article .docx

Using GOOGLE Scholar, you must choose a scholarly journal
article on the topic of psychology. You may choose any article
you feel contributes to the field of psychology and will write a
5 page paper (including cover page and reference page) based
on the article.
Please use the following criteria when writing your paper:
Times New Roman. 12point. Double-spaced. APA Style.
Reference must be included at the end of the paper.
Please use the following website: https://scholar.google.com/
This paper is worth 100 points total. This must be submitted
prior to the start of class on
Monday Class, April 18, 2020, 11:59pm.
Tuesday Class, April 19, 2020, 11:00pm.
There will be 5 points deducted for every day the assignment is
late up to one
week. After that point, the student will earn a score of "0".
Introduction – 10pts
Introduce the topic and your reason for choosing this topic
Main topic- 45pts

f topic on a specific population (could be
cultural, the nurse, the
health care profession, the student, education) different from
the main focus. This
could be positive or negative or both- (15pts)
Summary- 10pts
Incorporate a minimum of 2 peer reviewed journal articles into
your paper to provide
insight to your topic- 15pts
APA format -10pts
Grammar, spelling, punctuation- 10pts
You may have no more than ONE direct quote. Must be cited
properly.
Length of paper is 2-3 pages. In addition you must have a title
page and a reference page.
Times New Roman 12pt. Font
One inch margins
Double spaced

U
ndertaking clinical skills is a central part of a nurse’s
professional role and successful clinical outcomes
depend on the competent performance of technical
procedures as well as an appropriate level of
understanding and a professional attitude (McNett,
2012; Harmon et al, 2016). Therefore, clinical skills teaching is
a
vital part of the curriculum for pre-registration learners.
There is debate around whether skills teaching is the domain
of universities or practice placement settings (Borneuf and
Haigh,
2010). Francis (2018) suggests that, as curriculum and practice
pressures have changed over time, questions have arisen over
who is responsible for clinical skills teaching, with nurse
educators
not viewing it as their role and clinical staff having insufficient
resources to deliver the teaching (Borneuf and Haigh, 2010).
Tensions exist between the demands placed on nurse educators
to demonstrate excellence in teaching, research and maintaining
clinical credibility (Råholm et al, 2016). Leonard et al (2016)
argue that nurse educators do not need to undertake regular
clinical practice to demonstrate professional credibility in the
teaching environment of a university. Although it is suggested
Teaching clinical skills in pre-registration
nurse education: value and methods
Gary Francis and Martina O’Brien
ABSTRACT
This article explores the value of teaching clinical skills in pre-
registration
nurse education. It touches on stages of competence and the

knowledge
necessary to enable the learner to meet the standards of
proficiency expected
of registered nurses. Some contemporary issues around clinical
skills teaching
are discussed. How clinical skills can be taught and learnt as
well as common
problems encountered by learners and by educators are
highlighted. This
article also aims to stimulate discussion around the Nursing and
Midwifery
Council’s new standards of proficiency for registered nurses. It
discusses
how learners will be prepared to undertake all nursing
procedures outlined in
these standards within a changing healthcare education
landscape and an
increasingly complex health and social care environment.
Key words: Clinical skills ■ Simulation ■ Competence ■
Blended learning
■ Flipped classroom ■ Scaffold learning
Gary Francis, Associate Professor—Practice Skills Learning and
Simulation, School of Health and Social Care, London South
Bank University, [email protected]
Martina O’Brien Associate Professor—Adult Nursing, School of
Health and Social Care, London South Bank University
Accepted for publication: December 2018
that clinical skills should be taught by practitioners in the care
setting, in practice the capacity for doing this has declined
because
of busier environments, increased patient complexity and a
more

risk-averse culture (Staykova et al, 2017).
The traditional approach to clinical skills acquisition—‘see
one, do one, teach one’—is often questioned as it fails to check
if the student has learnt a skill correctly and has gained the
necessary understanding before practising on patients (Bradley,
2006; Staykova et al, 2017). Some argue that to reduce risk and
maintain high standards and safe levels of care, clinical skills
teaching should take place, at least in part, in a safe, simulated
environment first (McCutcheon et al, 2014; Gonzalez and
Kardong-Edgren, 2017).
The new Nursing and Midwifery Council (NMC) standards
of proficiency for registered nurses place a significant emphasis
on developing a broader range of clinical skills, with the aim of
ensuring newly qualified nurses are confident and proficient at
the point of registration (NMC, 2018a).
This article discusses some approaches and key concepts around
teaching clinical skills.
Teaching clinical skills: context
Harmon et al (2016) state that teaching clinical skills is
different
from teaching by traditional lectures. To teach a skill, educators
need to be competent at performing the skill themselves (Bland
et al, 2011; McCutcheon et al, 2015). McNett (2012) highlights
this is not always the case. Harmon et al (2016) suggest
clinicians
who are able to perform a complex clinical procedure routinely
can still find it a challenge to move into the role of an educator.
All registered nurses are required to support and facilitate
learners
to develop skills, knowledge and competence (NMC, 2018b),
but not all are professionally developed or prepared for this role
(Rebeiro et al, 2017).

Haraldseid et al (2015) say capable clinical skills educators are
knowledgeable, organised and up to date. This can often make
the less confident or less clinically current educators
uncomfortable
(Harmon et al, 2016; Aldridge, 2017). However, it is suggested
that even the most clinically current and competent educators
require clinical skills training to ensure their teaching and the
demonstration of skills remain consistent (Durham and Baker,
2014). Care must be taken to ensure minimal didactic delivery,
with plenty of time for learners to practise.
Herrmann-Werner et al’s (2013) study demonstrated that,
regardless of method chosen for teaching clinical skills, there is
a direct correlation between learner retention and quality of
performance in a simulated environment. Further exploration
452 British Journal of Nursing, 2019, Vol 28, No 7
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of how clinical skills teaching using simulation may affect
service
delivery and patient safety in clinical practice is recommended.
Stages of competence
Peyton (1998) advocates moving away from an ‘autopilot’
approach, which is often adopted for routine, day-to-day
practice
(where the expert is unconsciously competent) to an explicit
awareness of precisely what elements of a skill are required to
be able to execute a task (the expert becomes consciously
competent). Similarly, a novice is often unaware of what they
need to learn (they are unconsciously incompetent). Protecting
patient safety and enabling learners to become conscious of
their
limitations to undertake skills (so they become consciously
incompetent) is important, as this will make them aware of what
they do not know and what they need to know to perform safely.
Dreyfus and Dreyfus (1986) and Benner (1984) describe the
‘novice to expert’ continuum as a framework to position
developmental competence. They argue that, through
instruction,
practice and experience, skills can be mastered. Mastery of
complex skills often requires regular practice and application of
knowledge (Durham and Baker, 2014).
The novice to expert model identifies the novice learner as
someone who has basic reference knowledge, which informs
their practice when undertaking a skill, eg taking a set of vital
signs and knowing when to escalate. This develops as they

become
a more advanced learner and their experience develops into
coherent and context-specific knowledge eg understanding the
underpinning physiology of vital signs and being able to
recognise
signs and symptoms. This then informs their ability to execute
a skill or task with greater understanding.
Development evolves as experience grows and greater, detailed,
functional knowledge is acquired, which support a level of
competence and ability to think critically when undertaking
skills eg taking vital signs while carrying out a more advanced
assessment from which direct action can be initiated. When
proficiency is achieved (usually within 3-5 years of exposure),
learners can complete tasks and skills with ease and are able to
apply a much higher level of analytical thinking that develops
into expert practice (usually 5 years and longer of exposure)
(Benner, 1984). Gobet and Chassy (2008), among others, are
critical about the lack of solid evidence to support these stages
of development, citing popularity rather than proof of their
validity. Despite this, many institutions, academics and
practitioners
across the globe continue to use this framework to structure
their
clinical skills-based competency assessments (Gonzalez and
Kardong-Edgren, 2017).
Miller (1990) proposed a pyramid model to determine clinical
competency. This distinguishes between knowledge at the lower
levels and action in the higher levels. It argues that environment
and setting are key for practising and the assessment of skills.
Recently, two further stages have been added below ‘knows’;
these are ‘heard of ’ and ‘knows about’, which help to identify
where learners’ understanding starts (Mehay and Burns, 2009).
Critics suggest that a superiority or hierarchy of knowledge is
implied by this model and, as such, lower level knowledge or

competence (such as ‘knows’ or ‘knows how’) could be viewed
as inferior (Al-Eraky and Marei, 2016).
Approaches to teaching clinical skills
One standardised approach to teaching clinical skills is Peyton’s
four-step model (Peyton,1998). This takes a systematic
approach
to instruction that allows the student to become more familiar
with the skill through observation, then listening, followed by
talking through the steps and, finally, through practice. It is
commonly used in the teaching of basic life support
(McNett, 2012).
This model requires the trainer/educator to do the following:
■ Real life demonstration: the trainer demonstrates the skill
in its entirety in real time without commentary. This allows
trainees to observe mastery of the skill
■ Trainer talk-through: the trainer repeats the procedure
while explaining each step and manoeuvre, answering trainee
questions and clarifying any points
■ Learner talk-through: the trainee directs the trainer,
providing instructions to the trainer on each step and
manoeuvre as the trainer does the skill
■ Learner does: the trainee does the skill under close
supervision, providing a commentary on each action before
it is done.
Krautter et al (2011) found that this model was superior to
standard instruction with regard to psychomotor skill
performance
and professionalism. Learners performed the skill to the
required

standard for the first time more quickly. Nikendei (2014)
suggests
that this approach is well structured for less confident educators
and provides more clarity and opportunities for learners to
engage
in different ways. Munster et al (2016), however, found no
measurable short- or medium-term differences between learners
taught using this model and a traditional ‘see one, do one’
method
of teaching.
Bradley (2006) suggests that a mixed approach can add value
to skills teaching. Gonzalez and Kardong-Edgren (2017)
advocate
this to accommodate different learning styles and learner
preferences. Biggs and Tang (2011) also suggest that watching a
recording of a skill procedure can form part of the process. This
Figure 1. Miller’s pyramid of clinical competency (Miller,
1990; Mehay and
Burns, 2009)
Does
Shows how
Knows how
Knows
Knows about (new)
Heard of (new)
British Journal of Nursing, 2019, Vol 28, No 7 453

CLINICAL SKILLS
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would free the lecturer to spend time facilitating rather than
demonstrating the skill (Rutt, 2017).
Debriefing and feedback are essential components of the
learning experience and the acquisition of skills and knowledge
(Shinnick et al, 2011). Debriefing is in itself is a form of
clinical
teaching whereby reflection can contextualise learning to
prepare
safe and knowledgeable learners (Dreifuerst, 2015; Voyer and
Hatala, 2015). Providing feedback is a complex skill (Rush et
al,
2012), which often poses challenges for educators (Voyer and

Hatala 2015). Providing balanced structured feedback is
important
and helps to ensure learners feel supported then trusted and
more
confident to perform the skill independently or under
supervision
(Bland et al, 2010; McNett, 2012; Race, 2014).
Mentally rehearsing clinical skills, combined with physical
practice and subsequent repetition, can increase the confidence,
competence and consistency of those performing them (Harmon
et al, 2016).
Bloomfield and Jones (2013) explore other ways in which
skills are learnt; they describe the significance of using
simulated
patient scenarios to add context, including videos and manikins
as well as virtual/augmented reality to support skills
development.
Sherwood and Francis (2018) emphasise the superiority of
simulation over didactic instruction alone. Doolen et al (2016)
suggest that technology alone is not the answer but how it is
used in a wider context can contribute to achieving learning
outcomes.
Other important factors for achieving learning outcomes
include: a safe, non-threatening laboratory-learnt environment,
where skills, knowledge and professional attitude can be
developed
to reach a certain level of competence before exposure to
patients;
and receiving structured, targeted feedback (Durham and Baker,
2014).
McCutcheon et al (2014) found such approaches strengthen
face-to-face teaching of skills and help to provide a structure or

‘scaffold’ the learning for all levels of learner. Vygotsky (1978)
defined the concept of the ‘zone of proximal development’
where
the gap in knowledge between what the learner currently knows
and what they need to know to be deemed competent is
addressed. Scaffolding techniques, where the educator
collaborates
with, supports and guides the learner to achieve competency,
can bridge this gap (Sanders and Sugg Welk, 2005). McNett
(2012) suggests that competence has been achieved only when
a learner can discuss their knowledge (indications,
contraindications,
complications and their prevention), demonstrate the skill
(preparation, technique and dexterity) and consistently display
a professional attitude and good communication skills (consent,
comfort and dignity of patients, and escalation). Arguably, this
suggestion does not discriminate between levels of competence
in different levels of learners. Garside and Nhemachena (2011:
541) propose that determining levels of competency is ‘purely
in the eye of the beholder’ and, as such, adds to the subjective
nature of what competency really is.
Blended learning is defined as a combination of pedagogical
approaches that can enhance the learning experience and
academic achievement (Poon, 2013). It commonly comprises a
combination of online learning and teaching activities including
face-to-face methods (Poon, 2013). Blended learning is
favoured
for its student-centred approach to developing knowledge and
understanding via independent learning (Power and Cole, 2017).
It offers greater flexibility and has been found to improve
learners’
autonomy as well as reflection and research skills (Poon, 2013).
Different pedagogical approaches are needed to develop the
knowledge, skills, professional values and ethical

considerations
of the learner (Jokinen and Mikkonen, 2013).
The ‘flipped classroom’ learning approach is one such method
to enable the learner to acquire and develop their knowledge
outside the confines of the classroom or skills laboratory. It
involves a reversal of traditional teaching methods where the
learner is first exposed to content outside the classroom/skills
laboratory (Betihavas et al, 2016). Knowledge gained is then
brought into and applied in the educational setting, which
allows
the educator to spend time on higher-level application of
knowledge and skills (El-Banna et al, 2017).
Preparatory work to develop knowledge, such as watching a
video of the skill to be mastered, completing an activity such as
a quiz or reading a journal article, can be done at a time and
place that best suits the learner. Learners are then responsible
for
coming to class prepared with an understanding of the subject
matter to enable them to engage in the class activity
(McLaughlin
et al, 2014). This has the potential to transform learning that is
passive and teacher led to learning that is active and student
centred (Reed et al, 2015). Learner knowledge, skills and
attitude
can then be applied and demonstrated in the safety of the
clinical
skills laboratory.
This student-centred approach is closely aligned to that of
blended learning, where learning is brought to the student rather
than the student being brought to the learning, as happens in
the classroom (Kho et al, 2018). The flipped classroom
approach
acknowledges the concept of ‘adult learning’ or andragogy as

espoused by Knowles (1975), where learners are active rather
than passive participants in learning.
The theory–practice gap, defined as a mismatch between the
theoretical content taught in university and the realities of
clinical
practice (Gardiner and Sheen, 2016), is another concept that can
be addressed through simulated clinical skills instruction and
learning. Bridging the theory-practice gap is an important
aspect
of robust pre-registration nurse education and, while enhancing
learning, this approach also has the potential to positively affect
the delivery of healthcare practice and skills required for
lifelong
learning (Telford and Senior, 2017).
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Box 1. A scaffold for learning
Techniques that educators can use to build in structure
■ Self-assessment of prior knowledge
■ Quizzes
■ Video demonstrations
■ Discussion forums before and after activities
■ Class examples—mapping out significance, relationships and
impact
■ Cue cards supporting an activity, hints and suggestions
■ Question cards to challenge understanding and review
■ Worksheets
■ Peer-to-peer assisted learning
■ Handouts
Problems with skill acquisition
The role of the educator is to ensure an adequate description or
demonstration of the task has been given, identifying all the
elements of the task; however, learners may have difficulty
learning
a skill because they lack the physical ability or strength to
undertake
a task, or have a problem with hand-eye coordination (McNett,
2012; Ewertsson et al, 2015; Haraldseid et al, 2015). Additional
time may be required if the learner experiences difficulties.
Students may also learn the skill incorrectly in the first place.
They may experience barriers such as anxiety, intimidation
or perceived irrelevancy (Harmon et al, 2016). Other issues
might

include size of the class, level of supervision and guidance and
ability to practise the skill (Rutt, 2017).
Application in practice
The more practice a learner gets, the quicker competency is
normally achieved (Krautter et al, 2011; Race, 2014). Bland et
al (2011) observe that opportunities to practise skills in the
current
clinical climate can be ad hoc and rushed, and sometimes lack
consistency.
The use of simulation to support skill performance in a range
of real-time conditions and situations is an important aspect of
current teaching and learning strategies (Kunst et al, 2018).
Simulation can also help to support clinical skills learning by
unpacking human factors eg lack of learner confidence or
allowing more time for weaker or slower learners and non-
technical skills, which are important in effective collaboration,
communication and escalation of care (Bland et al, 2011;
McNett,
2012; Ricketts et al, 2012; Merriman et al, 2014).
Kunst et al (2018) suggest that, depending on the learning
outcomes, skills development may require a combination of
integrated scenario activity, low and high-technology static
models, and higher-fidelity simulation. This ensures that
learners
have the best opportunities to practise their standalone
psychomotor skills and more complex activities in context as
well as their communication skills in readiness for practice.
The pre-registration NMC (2018) standards of proficiency
for registered nurses continue to recognise the importance of
clinical skills development and the value of practice learning
provided through simulation. Before the new standards were
launched, up to 300 hours of clinical skills training could count

towards practice hours (NMC, 2010). In the new standards,
there
is no limit; instead, a less prescriptive approach that will allow
greater innovation and development of worthwhile learning
experiences for students has been taken (NMC, 2018a). This
will
enable learners to develop skills necessary for safe and effective
practice before they encounter difficult and unpredictable real-
world scenarios (Williams and Song, 2016).
Francis (2018) argues that, to ensure robust clinical skills
teaching that meets the requirements of the seven NMC
platforms
of proficiency (NMC, 2018a), educators should be clinically
current and knowledgeable in the range of techniques that can
be used to teach and facilitate skills development and
simulation.
This will likely mean more collaboration between higher
education institutions and practice partners to achieve the
correct
balance of teaching and learning strategies, simulation training
and real-world hands-on experience.
Conclusion
Clinical skills teaching is a fundamental part of professional
pre-
registration nursing programmes. Debate around whether skills
practice is undertaken in a university, on a practice placement
or a combination of both will no doubt continue. However,
what is clear is that learners must be practically as well as
theoretically prepared for their roles. Through a combination of
approaches, it is crucial that clinical skills are robustly taught
to
ensure the correct levels of knowledge are acquired and
practical
skills are mastered to ensure patient safety. It is also vital that

the
right professional attitude is maintained to promote comfort and
compassion in the care delivered to patients and clients.
Learners
should be encouraged to view their competence as a continuum
where to maintain safe and informed practice they are required
to perform and update their skills regularly. BJN
Declaration of interest: none
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KEY POINTS
■ Skills teaching should be provided by healthcare educators
who are up to
date and competent in their theoretical knowledge and practical
delivery,

and can role model best practice
■ Skills teaching should be reinforced in the clinical setting by
practitioners
who are able to support and encourage learners
■ The mastery of skills is essential to the development of safe,
confident,
competent and technically able healthcare practitioners
■ High- and low-fidelity simulation methods should be
employed to support
learners in skills acquisition and development
CPD reflective questions
■ What factors should be considered when deciding how to
teach different clinical skills?
■ Discuss the factors that can affect a learners’ ability to
demonstrate proficiency at a clinical skill in the simulated
environment
■ How could Peyton’s four-stage model be applied when
teaching skills to learners?
■ How could blended or flipped classroom learning contribute
to the acquisition of skills?
©
2
01
9

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may print, download, or email
articles for individual use.
Lila Leanne Bennett, MSN, RN; Alan Grimsley, PhD; Linda
Grimsley, PhD, RN;
and Jan Rodd, MSN, RN
The Gap Between Nursing Education and Clinical Skills
Abstract: New graduate nurses are often stressed
in the early months of their first position following
graduation. The researcher examined whether new

graduate nurses were ready for the workplace or if
there a gap between nursing education and clinical
skills, causing new graduates to feel less confident
and new supervisors/employers to be frustrated with
the graduates’ lack of readiness to be part of the
nursing team. The concern was whether the new
graduates had acquired the necessary clinical skills
while in their nursing education programs in order
for them to be a full team member upon graduation.
The model used to examine both important areas of
education and practice was Benner’s (1984) model
of skill acquisition. Thirty-three new graduates with
less than one year of experience participated in the
study.
Key Words: Clinical Skills Development; Clinical
Skills of New Graduates; Nursing Expertise; Ben-
ner ’s Model of Skill Acquisition
Introduction
Transition from nursing student to Registered Nurse has proven
to be a difficult transition. Some new graduate nurses are not
adequately
prepared to assume the role of a nurse without more
clinical experience. New graduate nurses face many
different challenges and enormous pressure to meet
professional expectations.
Health care consumers have expectations as to
how their care should be provided which can have a
negative effect on new graduate nurses whose skills
are not yet efficient. Additionally administration
pressures nurses to provide efficient, effective and
profitable care, which places pressure on nursing

programs to provide work-ready graduates. This
research reviewed nursing education and the readi-
ness of clinical skills of new graduate nurses.
Expertise in clinical nursing skills is necessary
to provide quality care. From an educational stand-
point, the amount of knowledge needed to care for
patients in a safe and
effective manner requires new graduate nurses to
embrace additional learning resources outside of
the traditional learning environments. According to
Dadgaran, Parvizy and Peyrovi (2012), the clinical
education a nurse receives is predictive of how a
nurse will perform in the clinical setting.
Researchers found the education of nurses did
not always prepare them for the different areas of
the hospital and there is a difference in what the
students learn and how that education is used in an
active clinical environment. Nursing students do
not select clinical placements during nursing school
and are not responsible for a full load of patients so
they do not acquire the skill of dealing with differ-
ent patients with different issues at the same time.
The ABNF Journal 96 Fall 2017
Nurse educators must adapt to a changing healthcare
environment that includes teaching technology for
medical records/charting, changing patient popula-
tions and an increasing number of disease processes.
Cheng, Tsai, Chang and Liou (2014) stated many
administrators are not confident with the new gradu-
ates’ ability to provide safe, efficient care, indicating

a possible need for an internship to transition from
school to the workplace.
Nursing programs that implement a transition
period during school which allows students to work
in a clinical environment with a full patient load
alongside an experienced nurse may help increase
clinical knowledge and competence of the new grad-
uates. Transition may provide new graduate nurses
increased confidence. There is stress on new nurses
to familiarize themselves with their new environ-
ment while they portray themselves as competent,
when in reality, the new nurse is still learning.
New graduate nurses are shocked to learn the extent
of their duties when they begin working in the clini-
cal area (Cheng et al., 2014).This reality shock is
experienced in four stages. In phase one new gradu-
ate nurses are excited about having a paying job and
are in a euphoric state (Cheng et al., 2014). In phase
two reality starts to set in and new nurses realize the
work environment is much different than the clinical
experience from school. In the third phase, the stress
level begins to lower because new nurses begin to
understand what is expected of them. In stage four,
new nurses develop a plan and begin to cope with
the stress and learn the duties of their job and how
to perform efficiently (Cheng et al., 2014). Stress is
part of nursing, but is increased due to the expecta-
tions to swiftly acquire their new roles and respon-
sibilities, learn the difference between theory and
practice and join a team where they must work well
with others.
Bjerknes and Bjprk (2012) explained that new
nurses were not educated in the clinical environ-
ment to be adequately prepared and other nurses,

patients and administrators had unrealistic expecta-
tions of their abilities. Many facilities have created
mentorship to provide graduates more time to gain
confidence in their ability to provide patient care.
According to Dyess and Sherman (2009), many new
nurses assume roles in specialty areas that require
extensive knowledge in those areas which are above
the level they received in school, requiring an ex-
tended orientation period.
New graduate nurses employed in rural areas
are expected to take on many different duties with-
out guidance from another nurse. The new gradu-
ate nurse in the urban area may better perform with
some autonomy because they know they are not
alone if they have questions (Dyess & Sherman,
2009) . Nurses who start out in urban areas have re-
sources from multiple nurses and physicians who are
not available to those in the rural setting. In many
instances, the nurses in the rural area are working
basically alone (Duchscher, 2009).
Duchscher (2009) stated that new graduate
nurses face challenges that affect their performance
during the transition from school to employment.
These challenges include level of knowledge, physi-
cal demands placed on them, stress of acceptance by
their peers and adapting to culture of their new en-
vironment. Concern about the competency of nurses
comes from an increase in morbidity and mortality
rates of hospitalized patients in the United States.
There is a high expectation on nurses, new and expe-
rienced, to provide their patients with both efficient
and safe care.
Do new graduate nurses lack the appropriate

education? According to McHugh and Lake (2010),
the teaching methods used by professors in nursing
programs have a huge effect on students’ learning
to make correct clinical decisions while employing
critical thinking. Clinical experiences are to help
students learn the psychomotor skills that the new
graduate nurse must have, skills also influenced by
the teaching methods which are employed. Recruit-
ing nurses from select programs educated with all
the necessary tools can help to bridge the gap; how-
ever, many programs produce new graduate nurses
with limited skills to apply in the real world.
Using a multi-level conceptual framework to
guide the study, the researcher examined the educa-
tion of new graduate nurses to include theoretical
and clinical areas that influence competence. The
competence of new graduates affects their ability to
practice effectively. New nurses need their peers and
patients to be understanding regarding their skills.
Benner’s model of skill acquisition can be used to
examine both education and practice areas and con-
sists of five stages of clinical competence (Landers,
2010) .
Novices are newly graduated nurses entering
the clinical area with basic knowledge learned from
clinical and laboratory practice with little knowl-
edge of the requirements of nurses in a clinical
environment. Strict guidelines and directions from
a preceptor are needed ensure duties are performed

as expected by the institution. Advanced beginner
nurses have begun to adapt to their environment and
have a marginally acceptable skill level they can use
in textbook situations; however, they continue to
need guidance from a preceptor. Competent nurses
have acquired some degree of mastery and can
respond under pressure in the clinical environment
but lack the speed necessary to complete their tasks
in a timely manner. Proficient nurses have learned
how to handle situations as a whole and can manage
clinical situations using inductive reasoning. They
have goals and are achieving them with a knowledge
base built up over years of experience. Expert nurses
can make decisions without guidance and solve
complex problems rapidly all while giving effective
and efficient nursing care.
Preceptors are pivotal in the learning process
so that nursing students model excellent care after
watching their educators complete the task the cor-
rect way. Nursing student then move to the clinical
practice environment with the knowledge to provide
nurturing care.
The hypothesis for the study was: New graduate
nurses are not ready for the workplace because of a
gap between nursing education and clinical skills.
The following definitions applied to this study.
1. Expertise is the possession of expert skill or
knowledge in a particular field that allows one to
proficiently perform specific tasks.
2. Nursing education is the transmission of both
practical and theoretical knowledge to develop

competent nurses.
3. Nursing practice is the act of protecting and pro-
moting good health while preventing illnesses
and injuries and entails application of knowledge
acquired.
4. Quality care aims at increasing the likelihood of
desirable and consistent health outcomes with
current knowledge within a given profession.
Nurses are evaluated for the care they provide,
not only by administrators but also by patients for
whom they care. They are expected to provide excel-
lent, competent care at all times. It is vital that edu-
cational institutions offer a curriculum that provides
nursing students with the educational experience
that provides them the tools to move into the clinical
practice field at a competent level.
LITERATURE REVIEW
Nursing professionals provide services for
complex patients in many different types of facili-
ties. Upon graduation, use of clinical and practical
skills along with good clinical judgement will give
new nurses the ability to smoothly transition into
the workplace. Decisions for patients come with a
great deal of responsibility which may cause stress
on new graduates who do not feel prepared. Chal-
lenges include psychological stress along with the
physical stress of learning a new job. Certain things
may need to be implemented to narrow the gap such
as a longer orientation, more hands-on training or a
mentorship program.

In the workplace, new graduates have numerous
transition challenges that affect their performance
(Duchscher, 2009). Those challenges are related to
physical, social, intellectual, cultural and psycholog-
ical changes and come about as new graduate nurses
adjust to the new environment. New nurses may ex-
press their stress through emotions and feelings such
as nervousness, insecurity, self-doubt and feelings of
inadequacy.
Duchscher revealed a gap between nursing
education and clinical skills when new graduates
move into professional workplaces; a failure of
the educational program curricula not linking with
workplace expectations, thus new graduates not be-
ing adequately prepared to join the workplace. Such
negative effects may diminish the delivery of high-
quality healthcare by new graduates.
Numminen et al. (2014) analyzed whether
nurses’ education met the requirements for practice
in the working field. They examined reviews from
nurse administrators and nurse lecturers about the
new graduate nurses’ professional abilities, who con
cluded that skills among the new graduates did not
compare to those of experienced nurses. They sug-
gested that efficient collaboration between instruc-
tors and practice administrators before the students
completed their education could help ensure new
graduate nurses were ready for the workplace. They
concluded that the lack of collaboration between
the instructors and administrators was among the
key factors contributing to the emergence of the rift

between clinical skills and nursing education in new
graduate nurses.
Wu, Fox, Stokes, and Adams (2012) sug-
gested that new graduate nurses were affected by
work-related stress which interfered with safety
precautions and made the nurses commit numerous
medication errors. The authors stated that the reason
for the work-related stress was inadequate prepared-
ness of the nurses after completion of their educa-
tion. Further, Wu et al. showed that as most nurses
transitioned into the workplace they did not exhibit
adequate skills to enable them to operate equipment
in the workplace, reflecting a gap between education
and the work place environment.
Yeh and Yu (2009) studied causes of work stress
and factors that influenced new graduates to stay
or quit work. The authors suggested that the first
month was most stress intensive for the new gradu-
ate nurses, and in the second month they considered
quitting. Moreover, new nurses who exhibited the
greatest gap were twice more likely to quit than
properly educated nurses. The gap of new graduates
was a result of inadequate mentorship and train-
ing programs in the nurses’ curriculum, inadequate
support from nurse administrators in assisting new
nurses to adapt to the new workplace, as well as
inadequate clinical practical for the students. The
study also supported that medication
errors and low-quality health care were derived from
unpreparedness of the new nurses.

McAllister, Happell, and Flynn (2014) attempted
to establish attributes and competencies of nurse
graduates through examining reviews of Austra-
lian nursing managers in a comprehensive nursing
program. They suggested that a gap was responsible
for the global shortage of highly qualified nurse
graduates who were well versed in knowledge, at-
titudes and scientific skills. Much of the Australian
curriculum lacked the practice perspective and relied
heavily on the academic perspective. They revealed
that curriculum issues also contributed to the gap in
practical skills and nursing education among new
graduates leading to a decrease in the quality of
health care.
Watt and Pascoe (2013) examined experience
in a university-owned clinic and how it affected the
perception of new graduates in the nursing pro-
fession. They reported that nursing students who
were schooled in an institution owned by a hospital
thought they were ready for the profession after
graduating. The reason was that the students were
exposed to the culture, environment and administra-
tion systems in hospitals or clinics. Interacting in
those environments and learning the different sys-
tems instilled confidence and skills into students,
preparing them for practice. Those phenomena
enhanced new graduates’ ability to access and utilize
medical information and resources at the workplace.
Saifan, AbuRuz, and Masa’deh (2015) sought
to establish the reasons as well as identify solutions
for the existence of a gap between education and the
workplace. They stated that student nurses thought
that the presence of underqualified lecturers was a

critical factor that contributed to the gap between
clinical practice and nursing education. Students
stated that there was an increased lack of interaction
between instructors who teach practical lessons and
those who teach theory lessons, which interfered
with their continuity of the educational process. As a
result, nursing students possessed inadequate sup-
port through their clinical training.
METHODOLOGY
The researcher utilized a quantitative descrip-
tive study design for data collection from newly
graduated nurses. This study explored whether there
was a perceived gap between nursing education and
level of clinical skills acquired and whether graduate
nurses were prepared for challenges that are part of
their job.
Participants in the study included 37 nurses who
were new graduates and had been in a clinical set-
ting between three months and one year. First-year
nurses can describe their experiences well because
they are still in the period of transition from college
training into places of work. Participants had the
ability to describe the experiences and challenges
encountered in the clinical area.
The researcher completed human subjects train-
ing and adhered to all ethical considerations. The re-
searcher sought informed consent from participants
before obtaining any information. Participants who
did not complete the Consent Form were excluded
from the study. The researcher protected study
subjects by keeping all information confidential with
only the researcher and the committee having access.

The researcher used a self-developed survey
based on previous studies to identify perceived gaps
existing between nursing education and the set of
skills acquired in school and whether nurses were
well prepared for their work. The researcher used
Survey Monkey® to collect data. In addition to the
demographic data, the survey consisted of 9 ques-
tions with “yes” or “no” answers.
Data were collected over a period of 10 days
to allow participants the opportunity to respond at
their convenience. Data were analyzed using Survey
Monkey® software that categorized information in
graphs and charts.
Research Findings
The study used a self-reporting questionnaire to
determine if graduates were ready for the workplace
A networking sample was collected from practic-
ing nurses using Facebook. The study had 37 re-
spondents. Inclusion criteria were registered nurses
with between 3 months and 1 year of experience.
Exclusion criteria included registered nurses with
over one year experience. Demographic data col-
lected were gender, age, length of practice, specialty,
region of country, prior experience and education.
Most respondents were female (84%); with 16%
male. There were 7 different age ranges from 18-75+

years; most were in three age ranges, 25-34 (n=9,
24%); 35-44 (n=12; 32%); and 45-54 (n=7; 18%).
Respondents’ time as a nurse, practice specialty
and region of the country where they were employed
were requested. Time as a nurse ranged from 3-6
months (n= 14; 38%), 6-9 months (n=2; 7%), and
9-12 months (n=21; 55%). Specialties included
medical-surgical (n=12; 32%), pediatrics (n=9;
24%), OB (n=6; 16%), ICU (n=4; 11%), and ER
Table 1. Education Preparation
Variable n %*
Educationally prepared for solo practice
upon graduation?
Yes 18 54.6
No 15 45.6
Adequate “hands-on” in clinical?
Yes 21 63.6
No 12 36.4
Under-trained for first job?
Yes 12 36.4
No 21 63.6
Were critical “hands-on” skills not
taught in school?
Yes 28 84.9
No 5 15.1
Should schools include

preceptorship in last year?
Yes 31 93.9
No 2 6.1
Other factors hindering you from
providing competent care?
Yes 10 30.3
No 23 69.7
Mentoring program at your institution?
Yes 14 42.4
No 19 57.6
Individual factors influencing your
competence as new nurse?
Yes 21 63.4
No 12 36.4
Organizational factors influencing
competence as new nurse?
Yes 20 60.6
No 13 39.4
N = 33
*Note - Numbers may not equal 37; Percentages may not equal
100.
(n=6; 16%). Although regions of the country listed

were North, South, East, and West, the respondents
came from the South (n=36; 97%) and East (n=l;
3%) only.
Respondents were asked if they had worked as
an assistant or nurse tech before becoming a nurse
as well as their level of education. Slightly more had
worked as an assistant (n=20; 54%) than those who
first started as a nurse (n-17; 46%). Education levels
were also diverse with 17 (46%) having an Associ-
ate degree; 11 (30%) Bachelor’s degree; 8 (22%)
Licensed Practical Nurse, and 3 (8%) Certified Nurs-
ing Aide.
The questions about educational preparation
required “yes” or “no” responses and are addressed
in Table 1.
DISCUSSION AND CONCLUSIONS
The respondents were nurses employed for
three months to one year. Findings were similar
to Duchscher’s (2009) who stated that nurses had
many challenges which caused anxiety, insecurity,
and self-doubt to which the new nurse must learn to
adjust. This finding was not surprising.
Most respondents felt they were provided
enough “hands on” clinical experience in nursing
school; findings opposite those of Wu et el. (2012).
The e findings may be attributed to the area in which
the new nurse was employed and the graduate’s pre
ceptor. Nurses who were not in a specialty area may
have felt more prepared.
Most respondents stated they were not under-

trained for their first job; findings similar to those
of Watt and Pascoe (2013). The researcher found
the data to be interesting as it indicated the nurses’
readiness may be linked to whether they were em-
ployed in a hospital facility where they trained.
An overwhelming majority of respondents felt
some critical hands-on skills were not taught in
nursing school; findings supported by Saifan et al.
(2015). Theory taught in the classroom is not always
being transferred to the clinical training environ-
ment, a disconnect between the educators in the two
areas. Ninety-four percent of the respondents felt
that a preceptorship should be included in nursing
school as it would provide real-world experience in
the clinical environment. Watt and Pascoe (2013) re-
ported increased readiness in students whose school
was owned by a hospital.
Most respondents stated not have a mentoring
program at their institution which could contribute
to the gap between education and clinical environ-
ment. Watt and Pascoe (2013) noted the importance
of the students being in the hospital environment
was exposure to the hospital and administration cul-
ture.
Of factors that influenced the competence of the
new graduate nurse, chief was stress. The way in
which the nurses handle stress may affect how suc-
cessful they are in their job. Organizational factors
also influenced the competence of new graduates
but was not surprising as new nurses are expected to
begin knowing what experienced nurses know. Yeh
and Yu (2009) postulated that the gap was created
because administration failed to assist new nurses

adapt to their new environment.
Several areas can help with the transition of
the graduate nurse to the workplace environment.
Theory and clinical educators must work together
to prepare the nurse. The administration has a vital
role in providing support necessary to reduce stress.
The need for a preceptorship program during the last
semester of nursing school may be a viable
option. New graduate nurses should not be expected
to be an expert. They need patients and staff to be
understanding of the learning process so that stress
will be reduced.
Further research should be pursued with a larger
sampling of the population and more detailed ques-
tions to better determine the reasons for the gap be-
tween nursing school skills and the first workplace.
A broader spectrum of the nursing population would
help determine if the problems were unique to the
South or generalized across the nursing spectrum.
This study examined if new graduate nurses were
ready for the workplace based on Benner’s Model of
Skill Acquisition. It appeared there were areas where
the nurses felt confident and there continued to be
areas of concern. More research is needed to deter-
mine if a preceptorship would improve new nurses’
readiness for the workplace.
Education is an important aspect of preparing
the nurse for real life situations. However, education
must include nursing theory and nursing practice
that are linked together by excellent instructors in
both areas. New graduate nurses need to feel confi-
dent and prepared when undertaking their roles in a
life-changing environment.

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Nurses’ Professional Competence. Scandinavian Journal
of Caring Science, 28(4), 812-821.
Saifan, A., AbuRuz, M. E., & Masa’deh, R. (2015). Theory
Practice Gaps in Nursing Education: A Qualitative
Perspective. Journal o f Social Sciences, 11(1), 20-29.
Watt, E., & Pascoe, E. (2013). An Exploration of Graduate
Nurses’ Perceptions of Their Preparedness for Practice
After Undertaking the Final Year of Their Bachelor of
Nursing Degree in a University-Based Clinical School
of Nursing. International Journal o f Nursing Practice,
79(1,23-30.
Wu, T.-Y., Fox, D. P , Stokes, C., & Adam, C. (2012). Work-
Related Stress and Intention to Quit in Newly Graduated
Nurses. Nurse Education Today, 36(6), 669-674.

Yeh, M.-C., & Yu, S. (2009). Job Stress and Intention to Quit in
Newly Graduated Nurses During the First Three Months
of Work in Taiwan. Journal o f Clinical Nursing, 78(24),
3450-3460.
Lila Leanne Bennett, MSN, RN, corresponding
author, is a 2017 graduate o f the M aster’s in Nurs
ing Program, Albany State University, Albany, Geor-
gia. Alan Grimsley, PhD, Linda Grimsley, PhD,
RN, and Jan Rodd, MSN, RN are currently Albany
State University faculty members. Ms. Bennett may
be reached at: [email protected]
CALL FOR REVIEWERS
The ABNF Journal, official journal of the
Association of Black Nursing Faculty Inc., has
issued a call for reviewers. Anyone interested on
serving on the Editorial Review Board, please call
or e-mail the editor:
Dr. Linda Amankwaa, FAAN
Department of Nursing
Albany State University
Albany, GA 31705
[email protected]
229-291-4292 (Office)
http://dx.doi
http://dx.doi
http://dx.doi.Org/10.1016/j
http://dx.doi.org/10.3928/00220124-20090824-03
http://dx.doi.org/10.1046/jT365-2648.2000.01605.x
http://dx.doi.org/10.1046/jT365-2648.2000.01605.x

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