2018 New Graduate Nurses Preparation for Recognition and Prevention of Failure to Rescue (AQA PDF)

Accepted: 10 August 2017 DOI: 10.1111/jocn.14016 ORIGINAL ARTICLE New graduate nurses’ preparation for recognition and prevention of failure to rescue: A qualitative study Elizabeth K. Herron PhD, RN, CNE, Assistant Professor School of Nursing, James Madison University, Harrisonburg, VA, USA...

Accepted: 10 August 2017 DOI: 10.1111/jocn.14016 ORIGINAL ARTICLE New graduate nurses’ preparation for recognition and prevention of failure to rescue: A qualitative study Elizabeth K. Herron PhD, RN, CNE, Assistant Professor School of Nursing, James Madison University, Harrisonburg, VA, USA Aim and Objective: To explore new graduate nurses’ experiences with recognition and prevention of failure to rescue. Correspondence Elizabeth K. Herron, School of Nursing, Background: Failure to rescue is recognised as a quality–of-care indicator, a core James Madison University, Harrisonburg, VA, measure of nursing care in hospitals, and a determinant for staffing in acute care USA. Email: [email protected] facilities. Clinical reasoning is an essential component in preventing failure to rescue and should be emphasised in nursing education and new graduate orientation. Many Funding information Thank you to the University of North nurses graduate without the ability to use clinical reasoning in providing patient care Carolina Charlotte School of Nursing which can lead to adverse patient outcomes. Director’s Research and Scholarship award for funding this qualitative study. Design: A descriptive phenomenological design was used. Methods: A purposive sample of 14 new graduate nurses from a nursing pro- gramme in the south-eastern USA, in practice for no more than eighteen months, was recruited. Individual one-on-one interviews were conducted from January–June 2016 and audio-recorded for accuracy. Data were evaluated using the consolidated criteria for reporting qualitative research (COREQ) guidelines. Recordings were pro- fessionally transcribed and reviewed. Results: Using Giorgi’s methods for data analysis, five main themes were discerned in the data: clinical preparation in school; experience with emergent situations; development of clinical reasoning; low confidence as a new graduate; and respond- ing to emergencies. Within each theme, subthemes emerged. Conclusion: The words of the participants provided rich detail into the preparation of new graduate nurses and how nurse educators, managers and preceptors can better focus learning opportunities to prepare them for practice. Experiential learn- ing combined with collaboration among education stakeholders will lead to a better prepared and more confident nursing work force. Relevance to clinical practice: Better preparation and continued support of new graduate nurses lead to positive patient outcomes and more satisfaction with their choice of nursing as a profession. KEYWORDS clinical preparation, failure to rescue, new graduate nurse, nursing education, patient deterioration e390 | © 2017 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/jocn J Clin Nurs. 2018;27:e390–e401. HERRON | e391 1 | INTRODUCTION What does this paper contribute to the wider Failure to rescue (FTR) is recognised as a quality-of-care indicator global clinical community? (Bobay, Fiorelli, & Anderson, 2008; Classen, 2010; Friese & Aiken, 2008; Griffiths, Jones, & Bottle, 2013; McHugh & Stimpfel, 2012; New graduate nurses are the front line of bedside nurs- ing care and should be prepared to recognise and Silber, Williams, Krakauer, & Schwartz, 1992), a core measure of respond to the deteriorating patient. nursing care in hospitals (Askew, Trotter, Vacchiano, Garvey, & Voercash, 2012; Clarke & Aiken, 2003) and a determinant for staff- Nurse educators in nursing programmes and acute care facilities have a duty to provide new graduate nurses ing in acute care facilities (Aiken, Clarke, Sloane, Sochalski, & Silber, with opportunities to develop and enhance clinical rea- 2002; Aiken et al., 2011). FTR has been defined as the ability of soning in patient care. nurses to recognise and prevent fatal complications from occurring while providing direct patient care (AHRQ, 2010; Bobay et al., 2008; Schools of nursing and healthcare facilities who hire new graduate nurses need to collaborate to determine essen- Schmid, Hoffman, Happ, Wolf, & DeVita, 2007). As a concept, FTR tial learning experiences necessary to prepare new grad- has been studied under various terms including nursing surveillance, uates for practice. situational awareness and vigilance. Current research on FTR is focused on registered nurses in practice and methods by which con- tinuing education can enhance knowledge and skills to improve patient care outcomes. Few studies have been conducted to focus supervised experience where a clinical instructor, or nurse preceptor, on new graduate nurses and their preparation for FTR situations in guides the decision-making and often ultimately makes the decision. practice. This study explored new graduate nurses’ experiences with clini- Various literature reviews have been performed related to the cal reasoning and patient care in their prelicensure nursing pro- use of simulation to introduce the concept of a patient in crisis to gramme as well as during new graduate orientation. nursing students and nurses with the intention of improving their Phenomenological research seeks to explore an experience and ability to recognise emergent situations and act accordingly (Fisher & “grasp the essential meaning” of it (Van Manen, 1990, p. 77). King, 2013; Gibson, Dickson, Lawson, Kelly, & McMillan, 2015; Sch- Through reflection on the experiences new graduate nurses have mid et al., 2007). Research indicates that clinical reasoning is an had with the deteriorating patient, the phenomenon of failure to res- essential component in preventing FTR and should be emphasised in cue can be better described and defined. The focus of the study was nursing education (Schubert, 2012). It has also been demonstrated on new graduate nurses’ recognition and prevention of FTR and that nursing students should be trained in emergent situations while how nurse educators can better support new graduates’ entry to in nursing school to further prepare them for practice (Gibson et al., clinical practice. 2015; Liaw, Rethans, Scherpbier, & Piyanee, 2011; Liaw, Scherpbier, Klainin-Yobas, & Rethans, 2011). 1.2 | Purpose The aim of this study was to explore new graduate nurses’ percep- 1.1 | Background and significance tions of their preparation for recognition and prevention of adverse Providing safe and effective patient care is an essential goal of nurs- patient events. Two research questions were explored: ing. The American Association of Colleges of Nursing has stressed that positive patient care outcomes are related to the ability of 1. Do new graduate nurses perceive their preparation in nursing nurses to clinically reason through both emergent and nonemergent school as providing them with the clinical reasoning abilities nec- situations and make sound clinical decisions. Benner, Sutphen, Leo- essary to provide safe and effective patient care? and nard, and Day (2010) and colleagues defined clinical reasoning as the 2. Do new graduate nurses perceive their orientation to their clini- ability of nurses to consider assessments, patient trends and experi- cal unit as adequate to prepare them to use clinical reasoning in ences to recognise changes in a patient’s clinical condition. In their providing safe and effective patient care? 2010 report, the Institute of Medicine (IOM) called for reform in nursing education to prepare new graduates to use clinical reasoning 2 | METHODS to improve patient care outcomes. Research indicates that many nurses graduate without the ability to use clinical reasoning in pro- 2.1 | Design viding patient care (Benner et al., 2010). Although new graduate nurses cannot be held responsible for clinical reasoning at the same A descriptive phenomenological approach was used to explore new level as an experienced nurse, it is the duty of nurse educators to graduate nurses’ perceptions of their preparation and training in prepare new graduates for safe clinical practice. However, new grad- recognising decline or deterioration in acutely ill patients. uates enter practice without the experience to make informed clini- Phenomenological research explores the lived experiences of the cal judgements. Most experience gained in nursing school is participants holistically (Van Manen, 1990). The researcher seeks to e392 | HERRON find meaning in a phenomenon through becoming immersed in the 2.4 | Data analysis participants’ words. This approach was appropriate in striving to bet- ter understand the experiences of the new graduate nurse. Phenomenological analysis of the data began using the methods of Giorgi (1985) which include reading and rereading the data to iden- tify themes and subthemes within the data that consistently came to 2.2 | Setting/sample ~ a’s (2016) methods of first and light. Coding followed using Saldan Criteria for participation included having graduated from an accredited second cycle coding, searching for meaning and then categorising nursing programme within the last eighteen months and employed as a the data to interpret the main ideas expressed by the participants. registered nurse, ability to read, write and speak English, and agreement ~a (2016) viewed qualitative research as a cyclical process that Saldan to be audio-recorded. As there is variation in length of time from gradua- requires reading the participants’ words more than once to ascertain tion, successful completion of the National Council Licensure Examina- their meaning. After reviewing the transcripts for errors and inserting tion (NCLEX), employment as a registered nurse and length of facility field notes, the researcher deleted all audio recordings. COREQ orientation, the researcher extended inclusion criteria beyond one year guidelines were followed. to capture participants with differing levels of experience at the bedside. Participants were assured of confidentiality as well as the voluntary nat- 2.5 | Trustworthiness ure of the study. Recruitment was conducted via email or private Face- book messaging by the researcher to recent graduates of a nursing Lincoln and Guba’s (1985) four criteria for trustworthiness (credibil- programme in the south-eastern USA. Authorisation to conduct the ity, dependability, confirmability and transferability) were used to study was granted from the appropriate institutional review board (IRB). ensure rigour in the qualitative process. Notes were taken during the All participants signed an informed consent prior to being interviewed. interviews and while data coding to capture the participants’ voices and the meaning behind their words and to assist in eliminating potential bias or misinterpretation. Data analysis began with the first 2.3 | Data collection interview and continued through formulation of the five themes, the Interviews were conducted either in person or via SkypeTM or Face- various subthemes and into reporting of the findings. In qualitative TM Time and were audio-recorded to ensure the participants’ words research, the data lend itself to interpretation by the researcher. The were accurately captured. A demographic questionnaire and a script themes extrapolated from the data were supported with rich data of interview questions were prepared (Table 1), submitted to the and use of participant’ own words added to the authenticity. Data IRB and approved for use. All interviews were conducted by one saturation was reached early in the process; however, the researcher researcher and audio recordings were sent via secure email to a pro- continued to read and reread each transcript with attention to detail. fessional transcriptionist. During the interviews, the researcher took The lived experiences of the participants were revealed and not sub- notes, used probing questions to further explore participants’ ject to bias of the researcher. responses and observed body language and facial expressions throughout. Participants were provided with information related to 3 | RESULTS dissemination of the research findings and given time to ask ques- tions related to the basis for the research. Audio recordings were 3.1 | Sample transcribed professionally and made available to the researcher as word documents. A total of 14 (n = 14) new graduates were interviewed for the study and data saturation was met. Demographic data were collected related to age, gender, length of new graduate orientation, unit T A B L E 1 Interview guide where employed and whether or not their orientation included a Sample interview questions Sample probing questions new graduate residency programme. The sample was all female and 1. Tell me how your prelicensure 1. Are there any other situations ages ranged from 22–24 years. Length of new graduate orientation nursing programme facilitated during orientation or your ranged from 6 weeks–15 weeks with 8 weeks being the most com- your development of clinical first few months off reasoning. orientation where you mon time frame (n = 6). One participant was still on orientation at 2. Describe your orientation experienced clinical decision- the time of the interview. Eight participants were employed on med- programme to the unit and making in preventing an ical–surgical units. The remaining participants (n 5) were on higher facility where you are currently adverse outcome? acuity units. Of the 14 new graduates, six were oriented through a employed. 2. How specifically did new graduate residency programme. 3. Describe an example of a patient orientation help you with care situation you encountered clinical decision-making? during (nursing school/your 3. Describe teaching methods 3.2 | Themes and subthemes orientation) that required you your preceptor used to to use clinical reasoning to enhance your clinical Five main themes were discerned in the data: clinical preparation in prevent an adverse outcome. decision-making. school; experience with emergent situations; development of clinical HERRON | e393 T A B L E 2 Themes and subthemes Theme Subtheme Clinical preparation Learning environment in school “I felt in clinical I never really got to think for myself or at least get the opportunity to try a thing for myself.” Clinical groups too large “I would have liked a little bit more time, but there were ten of us to one clinical instructor... it was difficult for her to give us more time, but I understood.” Experience with Never saw an emergency in nursing school emergent situations “Definitely no one coded. Not anyone that I can remember having chest pain or respiratory distress, anything like that that I can remember.” Not one emergency during orientation “I didn’t expect a code to be called. I thought that we would try to handle what we could do while we were up there cause I didn’t deal with many emergency situations when I was in nursing school.” First week off orientation “It was my second night off orientation, like I was by myself, I mean there’s other people. It was my first experience of ‘What do I need to do next’?” Development of The big picture clinical reasoning “I guess I had to think about it more and learn to relate the little things to the whole big picture of what’s going on.” Getting the flow “at first I didn’t have as much independence as far as thinking and using critical thinking skills, but as time progressed, they allowed me to have more independence.” New graduate residency “Your unit works very closely with the overall residency program. Every new hire that got hired at that particular time are in the same residency program.” Low confidence Communication with providers as a new graduate “I’m still nervous of these things. There’s some doctors that are ~ they’re a little rude sometimes, but you just have to be stern at the end of the day and you have to make sure that you get things that you need for your patient. There’s some that are very nice, but some they don’t want to be bothered.” Overwhelmed with tasks “But me staying on this unit, I can’t do that because I just really feel like I’m just a pill pusher and just I don’t have time to really focus on just connecting with patients and doing everything that I want to do.” It finally clicked “Now that I’m off orientation I see myself progressing. I see myself thinking a little bit more critically and like I said before, everything from nursing school is coming back.” Responding to Something is not right emergencies “Or just when you don’t feel right about a patient, when you just have that gut instinct that something is not right.” Teamwork on unit “I actually do feel confidence cause all my co-workers are great. We all help each other out especially if we see that one of our co-workers is behind.” Rounding nurse and rapid response team “As soon as we call rapid response, a hospitalist has to show up, a respiratory therapist has to show up, my assistant manager has to show up, really everybody just swarms.” reasoning; low confidence as a new graduate; and responding to semester capstone or preceptorship course when clinical reasoning emergencies. Several subthemes, discussed below, emerged in the with complex patient populations became more the focus. Emphasis data further describing how the participants viewed both their on the how and why of nursing was dependent on the clinical undergraduate nursing preparation and their orientation to practice instructor, patient assignments and the number of students in the (Table 2). As new graduate nurses with less than eighteen months of clinical group. Within the clinical preparation theme, several sub- experience on the job, the participants had timely recollection themes arose. of their clinical courses in nursing school and how their learning progressed. 3.3.1 | Learning environment The structure of the clinical learning environment affected the expe- 3.3 | Theme 1: Clinical preparation in school rience the participants gained and their ability to develop clinical rea- Throughout the data, participants discussed their clinical experiences soning. Participants indicated they were watched very closely by in nursing school as being primarily task oriented prior to their final their clinical instructors and not given the freedom to make their e394 | HERRON own clinical decisions. Many believed they were not given the It was very, very helpful to have the instructors tell the opportunity to think for themselves, but were told what to do and students what they did, of course with teaching, but it how to do it. One participant stated: was even more helpful for the colleagues and I to all gather around and put in our thoughts to what the in the beginning of the program, they thought it all for instructor was telling us. me. And I would think to myself, ‘So that’s what you would do in this type of situation.’ But then later on, I Participants acknowledged that clinical group size and learning thought of all the ideas myself and just made sure that environments were not specifically controlled by the clinical instruc- was the right move to make. tors and appreciated the time they were able to spend with them discussing patient care and developing clinical reasoning. Not being able to make their own clinical decisions, with the support of their instructor or preceptor, prevented many of the 3.4 | Theme 2: experience with emergent situations participants from seeing the holistic picture of patient care. Partici- pants expressed their lack of seeing the whole picture in nursing Participants described their experiences with emergent situations in school: clinical courses, preceptorship and new graduate orientation. When participants were asked to relate their clinical experiences with dete- The patient was just kind of there and I didn’t riorating patients, many indicated they had never had an experience really know what was supposed to happen next. I with an emergency in nursing school or orientation. guess I had to think about it more and learn to relate the little things to the whole big picture of what’s going 3.4.1 | Never saw an emergency in nursing school on. Participants indicated they had never seen an emergency during nurs- The final clinical course, or preceptorship, was when many of the ing school and were “never assigned to the sickest patients.” One par- participants felt they learned the most about nursing practice: ticipant discussed an emergent situation during preceptorship: I thought that the preceptorship was really helpful. I [my preceptor] took the reins on some of it where I felt a don’t know if it was because we were more independent little uneasy cause it was my first time dealing with a or what... we got to see the bigger picture of everything really rapid type of situation. It was very much new, but I that was going on. was able to take some of that what we talked about cause I recently... had the same situation happen to me. Although the learning environment had a significant impact on clinical learning, other extraneous factors were discussed in detail. A Throughout the data, participants agreed that nursing school did major factor was the number of students assigned to one instructor not provide them with the experience needed to safely care for a at the clinical sites. patient who was deteriorating. Participants were then asked to dis- cuss experiences in new graduate orientation where they cared for a deteriorating patient. 3.3.2 | Clinical groups were too large Clinical groups of ten students to one instructor was a burden 3.4.2 | Not one emergency during orientation expressed by many participants: Participants echoed their comments related to nursing school clinical “A clinical instructor typically has ten people in a class when discussing their experiences in practice orientation: at once. Unless they are literally running all the time... you are really not going to have many opportunities” to Not one emergency patient during orientation, although discuss “this is what I learned in class and this is how to I did observe a code, but didn’t participate. I’m not sure apply it.” if anything major happened during orientation. Participants voiced their frustration with the lack of time the Participants indicated they were not given the most serious clinical instructor was able to spend with them promoting clinical patients during orientation and in fact often were given the most decision-making as well as assisting with complex patient care skills. stable patients so the preceptor could spend more time teaching them Many believed they ultimately learned about patient care on their about the flow of the unit. One participant extended orientation: own with the help of their peers. Several participants indicated they depended more on their peers than their instructors for learning dur- in my orientation, I hadn’t dealt with a rapid response ing the clinical day: and codes and stuff like that so I wanted two more HERRON | e395 weeks, and of course, I got two rapid responses back to It didn’t happen until I was forced to do it on my own. I back. was told what to think in nursing school, so it didn’t really happen until I became a nurse. An interesting point arose in the data and was communicated by several participants. Although emergent situations may not have Instructors who asked questions in clinical, class and simulation arisen in clinical orientation, many were exposed to their first code were the most helpful in stimulating the development of clinical rea- situation shortly after orientation. soning in the participants: She really took the time to sit down and talk with me 3.4.3 | First week off orientation and ask me how it was going with my patients and if I A recurrent subtheme throughout the data was the experience of had any questions about them and what was going on. having a patient code during the first week off orientation when If I had any questions, it seemed more like they wouldn’t they were on their own taking care of patients. Although many of answer the question, but say, tell me what you think the participants indicated they were not “alone” on the unit, their and then help you figure it out. first emergencies happened when they were not being followed by a preceptor: Many of the participants wanted to hone their skills in nursing school and did not focus on the clinical reasoning of why they were Emergent? I don’t think I had anybody that was like doing these tasks. One participant related nursing student expecta- that. Not in orientation, but when I was off orientation, tions to those of the new graduate: I did though. It was a week after orientation when I had an emergency happen, of course. “as a nursing student in clinical, I definitely felt like pretty confident in my nursing student abilities” but as a new grad- Many participants had never had any kind of emergent situation uate “more was expected of me.” The first day as a new grad, occur while they were providing care. One participant expressed not “I didn’t have to do everything for the patient, but I was still fully knowing what to do during the first emergent situation because expected to know kinda everything that had to be done.” it had never occurred before: Participants indicated, during orientation, some of the nurse pre- it was different for me because I didn’t have it during ceptors emphasised clinical reasoning with the new graduates: orientation, so I was kind of like, ‘I don’t know what I need to do’, but I just pretty much stayed and just clinical reasoning, there’s not always a protocol right in waited for the doctor to come and talked to the doctor. front of you to look at, it’s something that you have to talk out which we actually did. It really helped. We’re all The lack of experience with deteriorating patients and other there as a team most of the time. emergent situations while in nursing school and hospital orientation precluded many participants from developing the clinical reasoning Experiences during orientation differed for participants depend- necessary for recognising and preventing failure to rescue. Ultimately ing on the unit to which they had been hired. Length of orientation for many of the participants, the ability to clinically reason through a varied greatly and additional course work was included for some difficult patient situation did not begin to solidify until they had during orientation and not for others. Those participants hired onto begun practicing as a nurse. critical care units all went through a new graduate programme, while those hired onto medical–surgical units, for the most part, did not. 3.5 | Theme 3: development of clinical reasoning 3.5.2 | New graduate residency In nursing school, participants indicated their clinical reasoning began to develop, but without experience to support their learning. Over- Participants discussed the structure, length and effectiveness of their whelmingly, participants agreed clinical courses were the most help- clinical orientations. Orientation to medical–surgical units tended to ful in promoting clinical reasoning, but not all clinical instructors be shorter than orientation to higher acuity units and did not include helped with the process. outside course work off the unit. One participant began working in a hospital where all new graduates were placed in a new graduate res- idency programme: 3.5.1 | The big picture Participants agreed that clinical reasoning is an essential tool for suc- We had a lot of classroom time, and they were always cessful patient care. However, many indicated they did not develop doing some kind of program, talking about burnout, talk- clinical reasoning until after they graduated: ing about things that may make us nervous. e396 | HERRON The new graduate residency programme described by this partic- 3.6 | Theme 4: low confidence as new graduate ipant was developed to provide learning opportunities outside of ori- entation on the nursing unit. Simulated patient care scenarios, case During hospital orientation and into the first few months without a studies, discussions with experienced nurses and administrators and preceptor, new graduates began to find a routine for patient care; unit-specific courses on use of specialised equipment were all part however, confidence in their knowledge and abilities continued to of the year-long residency programme. Not all participants found the develop. new graduate residency programme particularly helpful, however, as this participant shared: 3.6.1 | Communication with providers I don’t know what purpose it serves. I remember one Communication with providers and members of the healthcare team class they were talking about something having to do was a major source of low confidence for the participants. Many with communicating. Like if you’re in a paging system. expressed they felt anxiety when calling providers coupled with their ‘What does this have to do with me?’ I’m in the ICU, lack of experience with the process. The nursing school experience physicians are there. If I need somebody I can go run teaches new graduates to be sure there is an order for every treat- and talk to them. This isn’t helpful. ment; however, many students never had an opportunity to call a provider. The structure of each new graduate residency programme is Once in orientation, many new graduates were given the phone specific to the facility offering it and can vary in length of time and for the first time to communicate with providers and take calls from types of educational courses provided. One participant discussed the the healthcare team: facility’s reasoning behind instituting the residency programme stat- ing: “the evidence is showing that people who have gone through My thing was taking the phone from my nurse. I didn’t this program are not burning out as fast and are not leaving after like to do that, I was very scared, but by the end of it I the one year mark.” took the phone and I was answering all the phone calls, but she would emphasise what we needed to improve a little bit more on and what we can kind of let go. 3.5.3 | Getting the flow New graduate nurses enter practice as novices who have practised Some participants experienced providers who were less than cor- under direct supervision over the course of their nursing programme. dial when they were called. One participant indicated providers Once on their own, these new nurses needed time to develop needed to be reminded that nurses are the eyes and ears for the organisation and prioritisation skills. They were challenged with find- patient: ing a routine: Sometimes when you’re frustrated, it comes out, and The first two months off orientation were more about you let the physician know... look I know you’re the finding who you are as a nurse and trying to get your doctor, but I’m looking at them for 12 hours plus, all feet wet. I found out who’s a good person to ask for help night, every night. I’m your eyes and ears while you’re and who’s, like they’ll help but it’s sometimes not the away from your patient. Some doctors can be very con- help you were looking for, so that was one of the biggest descending. I just think they just get more offended and challenges too during those two months. they feel like we don’t trust their judgment, but we also feel the same way, that they don’t trust our judgment. Many new graduates had never cared for a full patient work load. Several participants recommended new graduates Each new graduate came to the realisation that calling providers begin working on night shift to develop strategies and organisational was for the patient. Preparation for calling seemed to help the par- skills: ticipants decrease the anxiety related to communicating with the providers. At some point in orientation or shortly thereafter, partici- I also feel like starting off on night shift absolutely pants began to have more confidence in speaking with providers and made a world of difference for me in my clinical reason- requesting orders for their patients: ing because on night shift, yes you have your charge nurse and the rounding nurse and those resources, but It’s kind of like I know what I want now because I real- for the most part you don’t really have doctors that ized that when I sound like I’m a little confused or ques- are hanging out in the physician’s room charting that tioning what I want, then I have to keep calling them or you can poke you head in and ask questions. It is kind paging them over and over again, then when I’m just of like you need to be resourceful and figure it out straight to the point, ‘Okay can they have this? Yes or yourself. no?’ This is what they need. This is going on. HERRON | e397 Communication with providers was a prevalent source of anxiety Once they found their own way, the feeling of accomplishment was for new graduates; however, the feeling of being overwhelmed with discussed: patient care was also a common subtheme. It makes me feel like I did something right and like I actually contributed to a patient’s successful recovery 3.6.2 | Overwhelmed with tasks versus if I didn’t, imagine what could have happened. It’s New graduate nurses are overwhelmed in the first few months of weird, but I just like the feeling of knowing that I can orientation and into the first weeks to months off orientation with make the right decisions for the patients. all the tasks needing to be accomplished: You’re overwhelmed with all the tasks you have to do... so when you go into the patient’s room, you aren’t 3.7 | Theme 5: responding to emergencies focused on, is the patient okay, you’re thinking, I have to Participants began to develop a sense of intuition or a gut feeling as go do this and this and this. I just felt so overwhelmed. their experiences with patient care increased. Many discussed the feeling of knowing something did not look right, but not knowing Participants indicated they were overwhelmed with tasks and the reason. believed they could not provide the best patient care. They expressed frustration with the patient load and not being able to think like nurses. Many discussed concerns over having a high 3.7.1 | Something is not right patient load and being able to provide safe care: As a new graduate nurse, experience has not yet been obtained to back up intuitive feelings. Many participants expressed the feel- If you have five patients and you’re gone around the ings of knowing something was not right, but not knowing exactly floor for three hours, you haven’t seen what their heart what it was. Recognition that a patient “was completely different rate looks like in three hours and it could be dropping. ten minutes ago when I was in here” was a common thread So, I think it could be safer with more nurses. I feel like throughout the data. Participants expressed an ability to recognise I’m still able to use clinical reasoning, but when some- a patient’s condition has changed without really understanding thing is going wrong, I have to double-check about what what happened. However, with the lack of understanding of the patient it is because five is a lot for that floor. So, I process, the intervention and treatment pathways were also always have to rethink, okay, who is this person, or lacking: what’s going on with them? I can’t look at their informa- tion in depth as much. I don’t have as much time. So, with my patient I kind of had an iffy feeling. When you have an iffy feeling it’s never a good thing. I couldn’t After several weeks on the nursing units, participants began to put my finger on what was iffy to me, so I sat down with find a way to get the work done, with help from available resources. an experienced nurse and I went over all their vitals. I went piece by piece” to find out what was going on. “I mean, I knew what was going on, but I didn’t know. 3.6.3 | It finally clicked Participants discussed the time frame within which they began to A common determination among the participants was that when feel their organisation and prioritisation was beginning to take shape. vital signs were changing, even without all of the information, calling For most, the beginning of orientation was difficult. One participant for help was the best decision. Knowing who to call and when was indicated orientation was: an initial hurdle for most participants. As one participant eloquently described her decision-making process: The most stressful thing I have ever done. There were too many patients to worry about clinical reasoning. As Before the doctor, before MICU rounding nurse, I called a new nurse, you don’t really know how things are click- respiratory because I couldn’t get his oxygen up. ing together. What I mean by that is it took me about Whereas the first week off orientation, they [respiratory] six months before it finally clicked for me. It was an didn’t even cross my mind. Just situations like that, awesome moment. knowing who I can call in certain situations and what they can do for me to help prevent the patient from As new nurses, each participant had to find a personal system coding basically. that worked for them. After completing orientation and being on their own, participants expressed they were able to think more criti- Each participant discussed the necessity of support, guidance cally about their patients and provide better care. and mentoring from colleagues. e398 | HERRON Making use of available resources in the healthcare facility is crit- 3.7.2 | Team work on unit ical for the new graduate nurse when a patient’s condition is deteri- Team work among nursing staff was overwhelmingly described as orating. As the participants in this study indicated, nursing care is a essential to safe delivery of patient care and prevention of adverse team effort. The first resource for many of the participants was their outcomes. Confidence was increased with good teamwork on the charge nurse. After the charge nurse, the next step was often the unit. Each new graduate learned to navigate where to find help rapid response team (RRT). Most commonly, the RRT is comprised of and who to ask for help in situations beyond their knowledge and an experienced critical care nurse, a respiratory therapist and a experience: physician or other advanced care provider. An RRT was available in most facilities where the participants worked. Learning to call the I feel like we have a really good team on the floor that I RRT was a big step for many of the participants: work on, but yet you definitely have to have, just open communication and knowing not just asking people what So, there’s a step in between calling a code. You just call to do, but how to ask it in various situation. So, yes, the rapid responding team and if they start escalating, teamwork is very important. we call the code. You kind of have a resource there which is nice. Part of asking for assistance was determining who would be available to help and who would not. Participants indicated not One participant discussed her reasoning behind using the RRT everyone on the unit was helpful: and the rounding nurse: There are certain nurses which I feel like on every unit, I would rather look like an idiot asking questions than do they’re not the best as far as asking for help. There’s something blindly and have somebody dead. My ego is never a point on the unit where I feel like I don’t have not worth my license. one or two nurses that I can ask for help, which is good. Responding to emergencies, using clinical reasoning and commu- Other resources outside the nursing unit were also integral to sav- nicating with the healthcare team consistently arose in the discus- ing the deteriorating patient. Participants discussed the assistance pro- sions with the participants in this study. A participant very vided by healthcare providers with more experience and knowledge. eloquently summed up what new graduates bring to practice: I think there’s a certain amount of knowledge you have 3.7.3 | Rounding nurse and rapid response team to know to start. There’s a certain way of thinking you Many of the facilities had a rounding nurse who was an experienced have to have. You have to have a certain level of clinical critical care or emergency department nurse who was available to reasoning. You may not know every single thing in the assist the medical–surgical unit nurses with patients who were not world. No nurse does. No nurse ever will. You can’t be doing well. Having a resource such as a rounding nurse was most fully prepared when you leave nursing school. But you helpful to the participants in preventing emergent situations with kind of have the foundation and you build from there. their patients. The purpose of the rounding nurse is to help prevent rapid responses, to hopefully get to a point where we 4 | DISCUSSION can intervene before it becomes a rapid response, or God forbid, a code. I absolutely love the rounding nurses. The experiences of the new graduate nurses were detailed in the They stay down there with you when you have a patient participants’ words and the data provided a rich perspective of both going bad and they are a really, really great resource. nursing school and practice orientation. The five themes that arose captured the most relevant insight into the participants’ perceptions For most of the participants, the rounding nurse was an excellent of failure to rescue and their ability to recognise and prevent it. resource. However, frustration did arise for one participant when “Clinical preparation in school” brought to light the participants’ she tried to convince the rounding nurse that the patient was not appreciation of experiential learning and the benefit when clinical doing well: experiences mirrored nursing practice. It is well supported that expe- riential learning is the basis for the development of clinical reasoning If I feel like my patient is not doing good, I’m sorry (Dreifuerst, 2012; Kuiper, 2013; Levett-Jones et al., 2010) and that rounding nurse; you can be annoyed at me but I am call- experience is the key to appropriate nursing actions (Clarke & Aiken, ing you. You’re coming down and you’re looking at this 2003). Although clinical experiences were discussed as the backbone person. to bridging the gap between classroom and practice, many HERRON | e399 participants indicated there was a lack of suitable experiences to experience and the overwhelming feeling of overseeing several prepare them for the deteriorating patient. Recognising the signs of patient’s lives are each inescapable aspects of being a new graduate patient deterioration, although partially instinctive, cannot be fully nurse. Nurse educators, nurse managers and new graduate precep- developed without experience (Hart, Spiva, Dolly, Lang-Coleman, & tors owe it to the new graduate nurse to determine their knowledge Prince-Williams, 2016). For the participants, emphasis in both nurs- base, experience and level of confidence to produce the safest prac- ing school and new graduate orientation was more on care of the titioner and ultimately, the best patient outcomes. As the partici- stable patient and assuming the role of practicing nurse. “Experi- pants’ words in this study have revealed, the most efficient way to ences with emergent situations” did not randomly occur and were learn is to be given the opportunity to experience a situation and often not sought out as part of the learning strategy. receive guidance on clinical decision-making. “Development of clinical reasoning” was an important theme in the data as participants indicated it was the basis of their ability to 4.1 | Limitations recognise and prevent failure to rescue. Research has been con- ducted related to cognitive ability and how nurses use clinical rea- The sample for this study was purposive and recruited from gradu- soning to prevent patient deterioration (Acquaviva, Haskell, & ates of one nursing school in the south-eastern USA. The researcher Johnson, 2013; Liaw, Rethans, et al., 2011). The overarching percep- was an instructor in the nursing programme from which the partici- tion of the development of clinical reasoning in this study was that pants graduated and had directly supervised many of the participants it occurred after graduation. Participants indicated there may have in either didactic or clinical courses. Although the study was volun- been times during nursing school where they saw a glimmer of clini- tary and the researcher had no influence at the time of participation, cal reasoning being emphasised; however, nursing school clinicals the relationship between the researcher and the new graduate nurse were highly focused on skill acquisition and care of the stable participants had previously been developed. The possibility that the patient. As nursing stakeholders have posited, more focus on clinical participants took part in the interviews to further enhance that rela- reasoning in nursing education is essential to prepare new graduates tionship cannot be discounted. for clinical practice (American Association of Colleges of Nursing, 2008; Institute of Medicine, 2010; Kavanagh & Szweda, 2017; 5 | RELEVANCE TO CLINICAL PRACTICE National League for Nursing, 2003, 2005). New graduates enter practice with a generalist education and a 5.1 | Experiential learning with deteriorating knowledge base to provide safe and effective care. It is not surpris- patients ing that “low confidence as a new graduate” was a prevalent theme in the study. New graduates do not have the experience to guide Nursing education has received much criticism for lack of prepara- their decision-making (Gibson et al., 2015; Purling & King, 2012). tion for practice in new graduate nurses. Understanding the per- However, lack of confidence expressed by the participants spective of the student when developing courses and focusing on extended to other aspects of nursing related to decision-making the needs of the graduate nurse can aid in better preparation for that warrant closer exploration. Participants discussed anxiety and practice and better patient outcomes. Availability of suitable fear of communication with members of the healthcare team. Clear patients in clinical courses can be a barrier to providing care for communication in an emergent situation can be the difference unstable patients. Placing students in their final clinical courses in between failure to rescue and patient survival (Clarke, 2004; Clas- higher acuity environments would provide more experience with sen, 2010). Nursing managers, unit educators, charge nurses and less stable patients. Although experiences with emergent situations advanced practice team members should all be aware of the need may not arise and cannot as such be controlled, the ability to rea- for interprofessional communication and the barriers experienced son through an emergent situation can be practised through simula- by new graduates. Participants’ words in the study eloquently tion, exposure during clinical and in the orientation phase of entry described situations where their views, concerns and opinions were into practice. Nursing students and new graduates on orientation not validated by members of the healthcare team, which led them should not be shielded from the most difficult patients. With the to future situations of second guessing or hesitancy in communicat- guidance and support of experienced educators and experienced ing signs of deterioration. preceptors, student nurses and new graduates can provide care for Around 2005, hospitals, in an attempt to prevent failure to res- patients whose condition has begun to decline (Acquaviva et al., cue situations from occurring, began to develop rapid response 2013; Clarke & Aiken, 2003; Fisher & King, 2013). Research has teams (RRTs) (Hammer, Jones, & Brown, 2012; Parker, 2014). Partici- demonstrated that simulation is effective in preparing nurses for pants in this study indicated in “responding to emergencies,” the care of the deteriorating patient (Gordon & Buckley, 2009; Gibson RRT and/or rounding nurse in their institutions were invaluable et al., 2015); however, more research is needed to ascertain best resources when questions arose around a patient’s condition and practices in both nursing schools and healthcare facilities for the potential for deterioration. New graduate nurses in the study learned development of multipatient scenarios that will enhance the new early in their practice who their resources were and how to get help graduate’s ability to make safe clinical decisions when a patient is when the situation called for it. Overcoming low confidence, lack of deteriorating. e400 | HERRON ACKNOWLEDGEMENTS 5.2 | Coordination and collaboration with clinical partners Thank you to the participants in this study. Nurse educators must work closely with clinical partners to ensure students are getting the best possible clinical learning experiences. CONFLICTS OF INTEREST Coordination and collaboration with clinical partners to fully under- There are no conflict of interests to disclose. stand what new graduates need to be successful is essential. Part of that includes coordination with nursing unit management and staff nurses to ensure consistency in what students are learning when in CONTRIBUTION the clinical environment. Working with clinical partners in designing Study design: EKH; data collection and analysis: EKH; and manu- clinical experiences that will enhance the learning experience for script preparation: EKH. nursing students as well as better meet the needs of the facilities who will hire them will create better outcomes (Benner, 2012). The development of essential skills checklists by clinical partners as a ORCID guide for nursing programmes as to what is expected of new gradu- Elizabeth K. Herron http://orcid.org/0000-0002-6077-1259 ate nurses would help to bridge the gap between theory and prac- tice. Further research related to this collaboration will improve outcomes for facilities hiring new graduates and ultimately improve REFERENCES patient safety. Acquaviva, K., Haskell, H., & Johnson, J. (2013). Human cognition and the dynamics of failure to rescue: The Lewis Blackman case. Journal 5.3 | Staying relevant in new graduate residency of Professional Nursing, 29, 95–101. https://doi.org/10.1016/j.prof programmes nurs.2012.12.009 Agency for Healthcare Research and Quality (2010). Failure to rescue. For new graduate nurses, nurse residency programmes have become Retrieved from https://psnet.ahrq.gov/glossary/failuretorescue part of orientation in many acute care environments. In some facili- Aiken, L. 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