Debra Shipman, PhD, RN

New nurse graduates often have difficulty transitioning to the role of registered nurse (RN).¹ Given the complexity of the health care environment, the need is growing to prepare nursing students for nursing practice. Although nursing education provides students with a basis for practice, school alone cannot prepare them for actual practice in the hospital setting.² Compared with nurse residency programs, which provide extended postlicensure training, the national Veterans Affairs Learning Opportunity Residency (VALOR) program provides externships independent of nursing school. Externships allow students to train in a hospital setting (generally during the summer months) before becoming a licensed RN. Nursing students who are entering their senior year of coursework in a bachelor of science nursing program and who have a minimum 3.0 grade point average can apply for this competitive national scholarship offered at VAMCs. The VALOR program is a paid learning opportunity, and students gain hands-on clinical experience under the guidance of preceptors.

Little externship research exists in the nursing literature.^3,4 The authors conducted the present study to help fill the gaps in the literature and to add to the only other study findings on VALOR.³ This program, started in 1990 to aid in nursing recruitment and retention, offers students early exposure to the complexities of nursing practice.

The authors investigated RNs’ experience in the VALOR prelicensure externship during the nurses’ senior year of coursework and the impact of this experience on their nursing practice. The program offers 800 hours of hospital-based experience outside the classroom. New nurses who gained only limited clinical exposure in nursing school may feel insecure about their clinical skills.⁵ Casey and colleagues found that students want more clinical experience than offered by nursing school practicums.⁶ The VALOR participants obtain additional clinical time, which contributes to their self-confidence when transitioning to the RN role.⁷

Literature Review

New graduate nurses work in complex health care environments with unfamiliar technologies, shift hours, heavy patient loads, psychological and professional stressors, socialization problems, and patient safety issues.⁸ They often are unable to connect their educational experience with the realities of practice and find the work environment incongruent with their nursing school education.⁹ Although new nurses’ difficulty in transitioning to their professional role has been addressed in the literature, transitional experience has not improved.¹⁰ Studies have found that new graduate nurses want more support than is given and have suggested that unfamiliar workplace dynamics create stress for new nurses.¹¹

Anxiety, insecurity, and fear of failure are associated with the transition from student to practicing nurse.¹⁰ Because of the additional clinical experience gained in an externship, students likely are more self-confident when they assume the RN role.¹² White suggested self-confident students see themselves as nurses and feel capable of caring for patients.¹³ Externship experience makes the transition to professional nursing less stressful, because externship students obtain an inside view of nursing culture.¹⁴ Students increase their understanding of nurses’ multiple roles and responsibilities, because these programs focus on increasing clinical skills and competency.¹⁵ To perform successfully as RNs, new graduates need competencies and knowledge beyond those obtained in nursing school.¹⁶

In the nursing profession, an association between job satisfaction and turnover exists.^17,18 Of new graduate nurses, 35% to 69% leave their position within the first year of employment.¹⁹ Replacing nurses reduces hospital productivity and efficiency and increases cost.²⁰ New graduate nurses leave because they are dissatisfied with and overwhelmed by the complexity of the work environment.²¹ Prelicensure nurse externships can aid in recruiting and retaining new graduate nurses for the hospitals that host these programs.²² For host facilities, recruitment rates of 50% to 79% have been reported.^23,24

In a quantitative study, Nuttall surveyed 133 RNs about job satisfaction, role socialization, professionalism, and sense of belonging.³ Of these RNs, 34 had participated in VALOR and 99 had not. There was no evidence that the RNs with VALOR experience had a higher degree of professionalism, job satisfaction, or role socialization; only sense of belonging (age-adjusted) was higher for the VALOR group. The conflicting data on prelicensure externship outcomes call for further analysis of these programs.³ Nuttall noted that her study “was the first... to evaluate the VALOR program and future research [using a qualitative approach] is needed to identify additional outcomes related to this program.”³

Methods

This study using hermeneutic phenomenology was approved by the Salem VAMC in Virginia and by the institutional review board at Nova Southeastern University.²⁴ Study participants provided written informed consent before being interviewed.

Interviewees

Data Collection and Analysis

Data collection began in March 2013 with a pilot test of the interview questions for appropriateness. Open-ended, semistructured questions were used to elicit nurses’ descriptions of their experience. Field notes were written, and all interviews were tape-recorded and professionally transcribed verbatim. Data saturation was reached after 12 nurses were interviewed. Transcripts were analyzed and interpreted using van Manen’s line-by-line approach.²⁶ All 12 interviewees were invited to review the findings of the data analysis. Eleven of the 12 interviewees verified and validated the study findings.

Rigor using Lincoln and Guba’s criteria of credibility, dependability, transferability, and confirmability added trustworthiness to the study findings. Bracketing helped eliminate potential bias.²⁷ Credibility was achieved with prolonged engagement and triangulation. To further enhance credibility, the authors invited qualitative research experts to validate the emerging themes and create an audit trail. For dependability, a flow chart was created for use by researchers who might want to replicate the study. Rich, lengthy descriptions and interviewees’ quotations were provided so researchers could judge the study’s transferability to other settings. Maintaining an audit trail and having a doctor of nursing practice independently code the data aided with confirmability. This study used findings from the literature, audio recordings, member checking, and field notes to assess data accuracy.

Results

The overarching theme discovered in this study was confidence. Subthemes were transitioning to the RN role, making decisions, and interacting with interprofessional staff.

Confidence

Interviewees felt confident in transitioning to the RN role, making decisions, and interacting with interprofessional staff. They shared that they had applied to the externship to gain additional clinical experience and that the program increased their self-confidence with respect to transitioning to the new role as RN. However, it is possible that these interviewees were highly motivated and would not have had difficulty transitioning to the RN role—this is addressed in the Limitations section of this article.

Interviewees said they initially approached VALOR with fear and apprehension but completed it feeling confident about becoming an RN. One interviewee stated, “The VALOR program gave me the confidence in my own abilities, so I was not scared and had confidence that, yes, I could do this job.” Another said, “Honestly, the entire externship program, regardless of which question you ask, my answer is going to always fall back on confidence. I became prepared for the RN job, I feel, before I graduated because of the [externship] experiences.”

Transitioning to RN Role

Transitioning involved understanding the RN’s scope of practice and feeling clinically competent. Students worked 40 hours a week over the summer and gained firsthand insight into working as an RN daily. Interviewees believed completing the externship made it easy to transition to the RN role because they knew what to expect.

Working side-by-side with nurses, students gained insight into RNs’ responsibilities and scope of practice. Interviewees reported that, after the externship, they had a better understanding of their patient care and licensure legal responsibilities.

Students began to feel clinically competent during the externship. Interviewees shared that they had had several opportunities to practice basic skills, such as giving injections. One interviewee said, “I don’t think I tried to stick a single IV when I was in school or in clinical [training].” Interviewees also commented that repeatedly practicing skills increased their self-confidence.

Students also gained firsthand insight into working with veterans and their families. During the externship, they learned about communicating therapeutically, providing education for caregivers, and advocating for patients and their families. Before the externship, they felt apprehensive about communicating with patients. One interviewee said that after the program, “Eventually you had to talk to patients, and eventually figured it out that it wasn’t so scary.”

Students found that patients were not always happy with their care, and procedures did not always go as planned. They also discovered that education did not end with the patient; family members needed education as well. The externship experience heightened students’ awareness of the RN’s role as patient advocate. One interviewee explained it is the RN’s responsibility to intervene on the patient’s behalf. Interviewees were surprised that patients would not tell their health care provider that they did not understand what was said or that they wanted another course of treatment.

The externship helped decrease learning-related stress. Interviewees indicated they had learned without fear of reprisal. One described feeling free to learn: “Uninhibited learning...you can ask what you need to without fear of not graduating.” Externship students were able to focus on learning the RN role without worrying about the next test or grade. They felt free to ask questions without fear of failing their clinical rotation.

The supportive and nurturing relationships that students developed in VALOR also increased their confidence when transitioning to the RN role. One interviewee said, “There was never the sense of, no, you learn my way, or I don’t want you here.” Interviewees shared that they felt comfortable and supported.

Decision Making

Interviewees reported that after VALOR, it was easy to make decisions regarding nursing practice, delegation, care prioritization, and career choice. As students, they found the school clinical setting did not provide the decision-making opportunities VALOR did, and they quickly realized nursing practice involved more than making patient-care decisions. One interviewee said, “In a classroom, a picture is painted of an idealistic environment that may not truly mimic the hospital unit.”

Students became familiar with the practice of delegating care to the appropriate staff and the next shift. One interviewee said VALOR “provided me with a better understanding of delegation in my RN role.” VALOR participants discovered that, as new nurses, they were less anxious when delegating to others.

Before RN licensure, VALOR participants learned about prioritizing patient care. One interviewee said, “It’s like everybody has to be charted on, and all the medications have to be passed out, but it’s a matter of getting everything done while doing the more important and more dire things first.” Students learned that all aspects of nursing are important, but they had to make rational decisions.

Interacting With Professionals

Interviewees who had been in VALOR said interacting with interprofessional (different disciplines) staff contributed to their working comfortably in teams and collaborating with others. Their collaborative relationships with physicians would help them later, when as new graduate nurses they again needed to work together with doctors. Typical comments were, “When I started as an RN, I felt I was not new at it because I had communicated with doctors in the externship program.”

Discussion

The present study found that nursing students who had been in the VALOR externship felt confident in their clinical skills when they were transitioning to the RN role. Other studies similarly have found that externship students were self-confident assuming the RN role, owing to their additional clinical experience.^12,28 The VALOR program allows students to work alongside nurses and receive hands-on experience while interacting with interprofessional health care teams. Findings of Nuttall’s quantitative study contradict those of the present, qualitative study. Nuttall used surveys and a control group, whereas this phenomenologic study captured the essence of study participants’ experiences through interviews.

The RNs interviewed in the present study discovered that, unlike nursing school, VALOR provided a realistic view of full-time work as an RN. This finding aligns with Starr and Conley’s finding that, before participating in an externship, most students were unaware of the extent of RNs’ roles and responsibilities, whereas after the program they understood these roles and responsibilities better.²⁸

The interviewees in this study thought VALOR improved their skills in communicating with patients, families, and interprofessional team members. Interviewees shared that they learned patient advocacy skills and that, through firsthand experience, realized nurses provide patients with a voice. Externships can help new graduate nurses become better communicators and can teach students the importance of patient communication and advocacy.¹²

This study also found that students wanted more exposure to realistic nursing environments, additional nursing skills practice, and more interaction with interprofessional team members. VALOR helped bridge the theory–practice gap by providing real-world nursing experience outside the academic environment and extra time for nursing skills development. In a study by Casey and colleagues, students indicated that the time allowed for nursing skills practice during school was inadequate.⁶

The VALOR program helped students learn about delegating work, whereas nursing school did not provide the opportunity to practice delegation. Other studies have corroborated that students do not practice delegation during nursing school clinical time.^29,30

Study respondents noted they could focus on learning without the fear of passing their clinical rotation. They felt supported by staff and were comfortable asking questions. White suggested that externship students who feel supported by nursing staff are able to focus on patients instead of on their discomfort.¹³ Rush and colleagues found that constraints on the student experience in traditional academic clinical rotations were replaced with “freedom and fearlessness in learning” in externships.³¹

Ten of the 12 study participants applied for a new graduate nurse position at the VAMC where they had their externship. A potential benefit to organizations that sponsor a nursing externship is the recruitment of new graduate nurses.¹⁴ Before applying for a full-time position, VALOR students had the opportunity to become familiar with the work environment and assess their fit with the employer. One student found staff nurse work “scary” and “stressful” and decided against it. She said the VALOR externship helped her realize exactly what nursing entailed: “Until this experience, I did not realize I would not like the hospital environment. This was a reality check for me.” Another student decided that working different shifts and working holidays would be difficult for her. These 2 students’ externship experience convinced them to seek other nursing positions.

Limitations

All participants in this study were nurses with excellent academic grades. It is possible they were highly motivated and might not have had any difficulty transitioning to the RN role. The principal investigator in this study was a VALOR program coordinator who knew 3 of the study participants—a potential source of bias. It is possible participants did not want to speak negatively about the program for several reasons: the interviewer was their coordinator, they received a salary during the externship, and several worked for the VA at the time of the survey.

Researchers have acknowledged the likelihood that not all VALOR students have positive experiences. It is possible that students with negative experiences did not discuss them or did not participate in the study. Increasing the size of the study sample may have brought in students with negative experiences. There is also the possibility of researcher misinterpretation and bias. Although bracketing was used, it was not possible to eliminate all potential sources of bias from this qualitative study.

Future Research

This is 1 of only 2 studies on the VALOR externship. Given the contradictory findings of these studies—Nuttall reported VALOR experience did not affect students’ transition to the RN role,³ whereas in the present study VALOR students thought the program positively affected their successful transition—additional quantitative and qualitative research is needed.

In addition, the low recruitment rate of VALOR students should be compared with other studies’ recruitment rates. The 38% VALOR extern recruitment rate for the period 2007 to 2012 is lower than the rate for other programs (G. Fuller, August 27, 2014, e-mail communication). The VALOR program does not track retention of participants after employment. Longitudinal studies should compare VALOR participants’ length of employment with that of nonparticipants’.

Conclusion

Externships provide clinical experience outside the classroom, expose students to the realities of nursing practice before graduation, and serve as a recruitment tool for hospitals. These programs, in conjunction with school-based practicums, increase exposure to the clinical environment. Before graduation, students have the opportunity to practice skills, interact with interprofessional staff, and experience different hospital units, all of which contribute to career decisions. The present study found that the VALOR externship helped new graduate nurses with their transition to the workplace. However, it is important to recognize the limitations of this study.

Interviewees indicated they were confident when they were transitioning to their new nurse role and caring for patients before receiving their RN licensure. New graduate nurses discovered they acclimated to the hospital environment quicker. The reality of working day-to-day in a hospital setting allowed students to select a compatible work environment and understand the daily challenges health care professionals encounter. Interviewees shared that they felt “like the RN” during the externship, which lessened the shock of actually assuming the RN role.

Van Manen asserted there is no conclusion or ending to a phenomenological study.²⁶ Continued research on hospital-based externships will demonstrate how these programs can assist in the development of new graduate nurses, ease their transition to practice, and benefit nursing education, practice, research, and public policy.

New nurse graduates often have difficulty transitioning to the role of registered nurse (RN).¹ Given the complexity of the health care environment, the need is growing to prepare nursing students for nursing practice. Although nursing education provides students with a basis for practice, school alone cannot prepare them for actual practice in the hospital setting.² Compared with nurse residency programs, which provide extended postlicensure training, the national Veterans Affairs Learning Opportunity Residency (VALOR) program provides externships independent of nursing school. Externships allow students to train in a hospital setting (generally during the summer months) before becoming a licensed RN. Nursing students who are entering their senior year of coursework in a bachelor of science nursing program and who have a minimum 3.0 grade point average can apply for this competitive national scholarship offered at VAMCs. The VALOR program is a paid learning opportunity, and students gain hands-on clinical experience under the guidance of preceptors.

Little externship research exists in the nursing literature.^3,4 The authors conducted the present study to help fill the gaps in the literature and to add to the only other study findings on VALOR.³ This program, started in 1990 to aid in nursing recruitment and retention, offers students early exposure to the complexities of nursing practice.

The authors investigated RNs’ experience in the VALOR prelicensure externship during the nurses’ senior year of coursework and the impact of this experience on their nursing practice. The program offers 800 hours of hospital-based experience outside the classroom. New nurses who gained only limited clinical exposure in nursing school may feel insecure about their clinical skills.⁵ Casey and colleagues found that students want more clinical experience than offered by nursing school practicums.⁶ The VALOR participants obtain additional clinical time, which contributes to their self-confidence when transitioning to the RN role.⁷

Literature Review

New graduate nurses work in complex health care environments with unfamiliar technologies, shift hours, heavy patient loads, psychological and professional stressors, socialization problems, and patient safety issues.⁸ They often are unable to connect their educational experience with the realities of practice and find the work environment incongruent with their nursing school education.⁹ Although new nurses’ difficulty in transitioning to their professional role has been addressed in the literature, transitional experience has not improved.¹⁰ Studies have found that new graduate nurses want more support than is given and have suggested that unfamiliar workplace dynamics create stress for new nurses.¹¹

Anxiety, insecurity, and fear of failure are associated with the transition from student to practicing nurse.¹⁰ Because of the additional clinical experience gained in an externship, students likely are more self-confident when they assume the RN role.¹² White suggested self-confident students see themselves as nurses and feel capable of caring for patients.¹³ Externship experience makes the transition to professional nursing less stressful, because externship students obtain an inside view of nursing culture.¹⁴ Students increase their understanding of nurses’ multiple roles and responsibilities, because these programs focus on increasing clinical skills and competency.¹⁵ To perform successfully as RNs, new graduates need competencies and knowledge beyond those obtained in nursing school.¹⁶

In the nursing profession, an association between job satisfaction and turnover exists.^17,18 Of new graduate nurses, 35% to 69% leave their position within the first year of employment.¹⁹ Replacing nurses reduces hospital productivity and efficiency and increases cost.²⁰ New graduate nurses leave because they are dissatisfied with and overwhelmed by the complexity of the work environment.²¹ Prelicensure nurse externships can aid in recruiting and retaining new graduate nurses for the hospitals that host these programs.²² For host facilities, recruitment rates of 50% to 79% have been reported.^23,24

In a quantitative study, Nuttall surveyed 133 RNs about job satisfaction, role socialization, professionalism, and sense of belonging.³ Of these RNs, 34 had participated in VALOR and 99 had not. There was no evidence that the RNs with VALOR experience had a higher degree of professionalism, job satisfaction, or role socialization; only sense of belonging (age-adjusted) was higher for the VALOR group. The conflicting data on prelicensure externship outcomes call for further analysis of these programs.³ Nuttall noted that her study “was the first... to evaluate the VALOR program and future research [using a qualitative approach] is needed to identify additional outcomes related to this program.”³

Methods

This study using hermeneutic phenomenology was approved by the Salem VAMC in Virginia and by the institutional review board at Nova Southeastern University.²⁴ Study participants provided written informed consent before being interviewed.

Interviewees

Data Collection and Analysis

Data collection began in March 2013 with a pilot test of the interview questions for appropriateness. Open-ended, semistructured questions were used to elicit nurses’ descriptions of their experience. Field notes were written, and all interviews were tape-recorded and professionally transcribed verbatim. Data saturation was reached after 12 nurses were interviewed. Transcripts were analyzed and interpreted using van Manen’s line-by-line approach.²⁶ All 12 interviewees were invited to review the findings of the data analysis. Eleven of the 12 interviewees verified and validated the study findings.

Rigor using Lincoln and Guba’s criteria of credibility, dependability, transferability, and confirmability added trustworthiness to the study findings. Bracketing helped eliminate potential bias.²⁷ Credibility was achieved with prolonged engagement and triangulation. To further enhance credibility, the authors invited qualitative research experts to validate the emerging themes and create an audit trail. For dependability, a flow chart was created for use by researchers who might want to replicate the study. Rich, lengthy descriptions and interviewees’ quotations were provided so researchers could judge the study’s transferability to other settings. Maintaining an audit trail and having a doctor of nursing practice independently code the data aided with confirmability. This study used findings from the literature, audio recordings, member checking, and field notes to assess data accuracy.

Results

The overarching theme discovered in this study was confidence. Subthemes were transitioning to the RN role, making decisions, and interacting with interprofessional staff.

Confidence

Interviewees felt confident in transitioning to the RN role, making decisions, and interacting with interprofessional staff. They shared that they had applied to the externship to gain additional clinical experience and that the program increased their self-confidence with respect to transitioning to the new role as RN. However, it is possible that these interviewees were highly motivated and would not have had difficulty transitioning to the RN role—this is addressed in the Limitations section of this article.

Interviewees said they initially approached VALOR with fear and apprehension but completed it feeling confident about becoming an RN. One interviewee stated, “The VALOR program gave me the confidence in my own abilities, so I was not scared and had confidence that, yes, I could do this job.” Another said, “Honestly, the entire externship program, regardless of which question you ask, my answer is going to always fall back on confidence. I became prepared for the RN job, I feel, before I graduated because of the [externship] experiences.”

Transitioning to RN Role

Transitioning involved understanding the RN’s scope of practice and feeling clinically competent. Students worked 40 hours a week over the summer and gained firsthand insight into working as an RN daily. Interviewees believed completing the externship made it easy to transition to the RN role because they knew what to expect.

Working side-by-side with nurses, students gained insight into RNs’ responsibilities and scope of practice. Interviewees reported that, after the externship, they had a better understanding of their patient care and licensure legal responsibilities.

Students began to feel clinically competent during the externship. Interviewees shared that they had had several opportunities to practice basic skills, such as giving injections. One interviewee said, “I don’t think I tried to stick a single IV when I was in school or in clinical [training].” Interviewees also commented that repeatedly practicing skills increased their self-confidence.

Students also gained firsthand insight into working with veterans and their families. During the externship, they learned about communicating therapeutically, providing education for caregivers, and advocating for patients and their families. Before the externship, they felt apprehensive about communicating with patients. One interviewee said that after the program, “Eventually you had to talk to patients, and eventually figured it out that it wasn’t so scary.”

Students found that patients were not always happy with their care, and procedures did not always go as planned. They also discovered that education did not end with the patient; family members needed education as well. The externship experience heightened students’ awareness of the RN’s role as patient advocate. One interviewee explained it is the RN’s responsibility to intervene on the patient’s behalf. Interviewees were surprised that patients would not tell their health care provider that they did not understand what was said or that they wanted another course of treatment.

The externship helped decrease learning-related stress. Interviewees indicated they had learned without fear of reprisal. One described feeling free to learn: “Uninhibited learning...you can ask what you need to without fear of not graduating.” Externship students were able to focus on learning the RN role without worrying about the next test or grade. They felt free to ask questions without fear of failing their clinical rotation.

The supportive and nurturing relationships that students developed in VALOR also increased their confidence when transitioning to the RN role. One interviewee said, “There was never the sense of, no, you learn my way, or I don’t want you here.” Interviewees shared that they felt comfortable and supported.

Decision Making

Interviewees reported that after VALOR, it was easy to make decisions regarding nursing practice, delegation, care prioritization, and career choice. As students, they found the school clinical setting did not provide the decision-making opportunities VALOR did, and they quickly realized nursing practice involved more than making patient-care decisions. One interviewee said, “In a classroom, a picture is painted of an idealistic environment that may not truly mimic the hospital unit.”

Students became familiar with the practice of delegating care to the appropriate staff and the next shift. One interviewee said VALOR “provided me with a better understanding of delegation in my RN role.” VALOR participants discovered that, as new nurses, they were less anxious when delegating to others.

Before RN licensure, VALOR participants learned about prioritizing patient care. One interviewee said, “It’s like everybody has to be charted on, and all the medications have to be passed out, but it’s a matter of getting everything done while doing the more important and more dire things first.” Students learned that all aspects of nursing are important, but they had to make rational decisions.

Interacting With Professionals

Interviewees who had been in VALOR said interacting with interprofessional (different disciplines) staff contributed to their working comfortably in teams and collaborating with others. Their collaborative relationships with physicians would help them later, when as new graduate nurses they again needed to work together with doctors. Typical comments were, “When I started as an RN, I felt I was not new at it because I had communicated with doctors in the externship program.”

Discussion

The present study found that nursing students who had been in the VALOR externship felt confident in their clinical skills when they were transitioning to the RN role. Other studies similarly have found that externship students were self-confident assuming the RN role, owing to their additional clinical experience.^12,28 The VALOR program allows students to work alongside nurses and receive hands-on experience while interacting with interprofessional health care teams. Findings of Nuttall’s quantitative study contradict those of the present, qualitative study. Nuttall used surveys and a control group, whereas this phenomenologic study captured the essence of study participants’ experiences through interviews.

The RNs interviewed in the present study discovered that, unlike nursing school, VALOR provided a realistic view of full-time work as an RN. This finding aligns with Starr and Conley’s finding that, before participating in an externship, most students were unaware of the extent of RNs’ roles and responsibilities, whereas after the program they understood these roles and responsibilities better.²⁸

The interviewees in this study thought VALOR improved their skills in communicating with patients, families, and interprofessional team members. Interviewees shared that they learned patient advocacy skills and that, through firsthand experience, realized nurses provide patients with a voice. Externships can help new graduate nurses become better communicators and can teach students the importance of patient communication and advocacy.¹²

This study also found that students wanted more exposure to realistic nursing environments, additional nursing skills practice, and more interaction with interprofessional team members. VALOR helped bridge the theory–practice gap by providing real-world nursing experience outside the academic environment and extra time for nursing skills development. In a study by Casey and colleagues, students indicated that the time allowed for nursing skills practice during school was inadequate.⁶

The VALOR program helped students learn about delegating work, whereas nursing school did not provide the opportunity to practice delegation. Other studies have corroborated that students do not practice delegation during nursing school clinical time.^29,30

Study respondents noted they could focus on learning without the fear of passing their clinical rotation. They felt supported by staff and were comfortable asking questions. White suggested that externship students who feel supported by nursing staff are able to focus on patients instead of on their discomfort.¹³ Rush and colleagues found that constraints on the student experience in traditional academic clinical rotations were replaced with “freedom and fearlessness in learning” in externships.³¹

Ten of the 12 study participants applied for a new graduate nurse position at the VAMC where they had their externship. A potential benefit to organizations that sponsor a nursing externship is the recruitment of new graduate nurses.¹⁴ Before applying for a full-time position, VALOR students had the opportunity to become familiar with the work environment and assess their fit with the employer. One student found staff nurse work “scary” and “stressful” and decided against it. She said the VALOR externship helped her realize exactly what nursing entailed: “Until this experience, I did not realize I would not like the hospital environment. This was a reality check for me.” Another student decided that working different shifts and working holidays would be difficult for her. These 2 students’ externship experience convinced them to seek other nursing positions.

Limitations

All participants in this study were nurses with excellent academic grades. It is possible they were highly motivated and might not have had any difficulty transitioning to the RN role. The principal investigator in this study was a VALOR program coordinator who knew 3 of the study participants—a potential source of bias. It is possible participants did not want to speak negatively about the program for several reasons: the interviewer was their coordinator, they received a salary during the externship, and several worked for the VA at the time of the survey.

Researchers have acknowledged the likelihood that not all VALOR students have positive experiences. It is possible that students with negative experiences did not discuss them or did not participate in the study. Increasing the size of the study sample may have brought in students with negative experiences. There is also the possibility of researcher misinterpretation and bias. Although bracketing was used, it was not possible to eliminate all potential sources of bias from this qualitative study.

Future Research

This is 1 of only 2 studies on the VALOR externship. Given the contradictory findings of these studies—Nuttall reported VALOR experience did not affect students’ transition to the RN role,³ whereas in the present study VALOR students thought the program positively affected their successful transition—additional quantitative and qualitative research is needed.

In addition, the low recruitment rate of VALOR students should be compared with other studies’ recruitment rates. The 38% VALOR extern recruitment rate for the period 2007 to 2012 is lower than the rate for other programs (G. Fuller, August 27, 2014, e-mail communication). The VALOR program does not track retention of participants after employment. Longitudinal studies should compare VALOR participants’ length of employment with that of nonparticipants’.

Conclusion

Externships provide clinical experience outside the classroom, expose students to the realities of nursing practice before graduation, and serve as a recruitment tool for hospitals. These programs, in conjunction with school-based practicums, increase exposure to the clinical environment. Before graduation, students have the opportunity to practice skills, interact with interprofessional staff, and experience different hospital units, all of which contribute to career decisions. The present study found that the VALOR externship helped new graduate nurses with their transition to the workplace. However, it is important to recognize the limitations of this study.

Interviewees indicated they were confident when they were transitioning to their new nurse role and caring for patients before receiving their RN licensure. New graduate nurses discovered they acclimated to the hospital environment quicker. The reality of working day-to-day in a hospital setting allowed students to select a compatible work environment and understand the daily challenges health care professionals encounter. Interviewees shared that they felt “like the RN” during the externship, which lessened the shock of actually assuming the RN role.

Van Manen asserted there is no conclusion or ending to a phenomenological study.²⁶ Continued research on hospital-based externships will demonstrate how these programs can assist in the development of new graduate nurses, ease their transition to practice, and benefit nursing education, practice, research, and public policy.

New nurse graduates often have difficulty transitioning to the role of registered nurse (RN).¹ Given the complexity of the health care environment, the need is growing to prepare nursing students for nursing practice. Although nursing education provides students with a basis for practice, school alone cannot prepare them for actual practice in the hospital setting.² Compared with nurse residency programs, which provide extended postlicensure training, the national Veterans Affairs Learning Opportunity Residency (VALOR) program provides externships independent of nursing school. Externships allow students to train in a hospital setting (generally during the summer months) before becoming a licensed RN. Nursing students who are entering their senior year of coursework in a bachelor of science nursing program and who have a minimum 3.0 grade point average can apply for this competitive national scholarship offered at VAMCs. The VALOR program is a paid learning opportunity, and students gain hands-on clinical experience under the guidance of preceptors.

Little externship research exists in the nursing literature.^3,4 The authors conducted the present study to help fill the gaps in the literature and to add to the only other study findings on VALOR.³ This program, started in 1990 to aid in nursing recruitment and retention, offers students early exposure to the complexities of nursing practice.

The authors investigated RNs’ experience in the VALOR prelicensure externship during the nurses’ senior year of coursework and the impact of this experience on their nursing practice. The program offers 800 hours of hospital-based experience outside the classroom. New nurses who gained only limited clinical exposure in nursing school may feel insecure about their clinical skills.⁵ Casey and colleagues found that students want more clinical experience than offered by nursing school practicums.⁶ The VALOR participants obtain additional clinical time, which contributes to their self-confidence when transitioning to the RN role.⁷

Literature Review

New graduate nurses work in complex health care environments with unfamiliar technologies, shift hours, heavy patient loads, psychological and professional stressors, socialization problems, and patient safety issues.⁸ They often are unable to connect their educational experience with the realities of practice and find the work environment incongruent with their nursing school education.⁹ Although new nurses’ difficulty in transitioning to their professional role has been addressed in the literature, transitional experience has not improved.¹⁰ Studies have found that new graduate nurses want more support than is given and have suggested that unfamiliar workplace dynamics create stress for new nurses.¹¹

Anxiety, insecurity, and fear of failure are associated with the transition from student to practicing nurse.¹⁰ Because of the additional clinical experience gained in an externship, students likely are more self-confident when they assume the RN role.¹² White suggested self-confident students see themselves as nurses and feel capable of caring for patients.¹³ Externship experience makes the transition to professional nursing less stressful, because externship students obtain an inside view of nursing culture.¹⁴ Students increase their understanding of nurses’ multiple roles and responsibilities, because these programs focus on increasing clinical skills and competency.¹⁵ To perform successfully as RNs, new graduates need competencies and knowledge beyond those obtained in nursing school.¹⁶

In the nursing profession, an association between job satisfaction and turnover exists.^17,18 Of new graduate nurses, 35% to 69% leave their position within the first year of employment.¹⁹ Replacing nurses reduces hospital productivity and efficiency and increases cost.²⁰ New graduate nurses leave because they are dissatisfied with and overwhelmed by the complexity of the work environment.²¹ Prelicensure nurse externships can aid in recruiting and retaining new graduate nurses for the hospitals that host these programs.²² For host facilities, recruitment rates of 50% to 79% have been reported.^23,24

In a quantitative study, Nuttall surveyed 133 RNs about job satisfaction, role socialization, professionalism, and sense of belonging.³ Of these RNs, 34 had participated in VALOR and 99 had not. There was no evidence that the RNs with VALOR experience had a higher degree of professionalism, job satisfaction, or role socialization; only sense of belonging (age-adjusted) was higher for the VALOR group. The conflicting data on prelicensure externship outcomes call for further analysis of these programs.³ Nuttall noted that her study “was the first... to evaluate the VALOR program and future research [using a qualitative approach] is needed to identify additional outcomes related to this program.”³

Methods

This study using hermeneutic phenomenology was approved by the Salem VAMC in Virginia and by the institutional review board at Nova Southeastern University.²⁴ Study participants provided written informed consent before being interviewed.

Interviewees

Data Collection and Analysis

Data collection began in March 2013 with a pilot test of the interview questions for appropriateness. Open-ended, semistructured questions were used to elicit nurses’ descriptions of their experience. Field notes were written, and all interviews were tape-recorded and professionally transcribed verbatim. Data saturation was reached after 12 nurses were interviewed. Transcripts were analyzed and interpreted using van Manen’s line-by-line approach.²⁶ All 12 interviewees were invited to review the findings of the data analysis. Eleven of the 12 interviewees verified and validated the study findings.

Rigor using Lincoln and Guba’s criteria of credibility, dependability, transferability, and confirmability added trustworthiness to the study findings. Bracketing helped eliminate potential bias.²⁷ Credibility was achieved with prolonged engagement and triangulation. To further enhance credibility, the authors invited qualitative research experts to validate the emerging themes and create an audit trail. For dependability, a flow chart was created for use by researchers who might want to replicate the study. Rich, lengthy descriptions and interviewees’ quotations were provided so researchers could judge the study’s transferability to other settings. Maintaining an audit trail and having a doctor of nursing practice independently code the data aided with confirmability. This study used findings from the literature, audio recordings, member checking, and field notes to assess data accuracy.

Results

The overarching theme discovered in this study was confidence. Subthemes were transitioning to the RN role, making decisions, and interacting with interprofessional staff.

Confidence

Interviewees felt confident in transitioning to the RN role, making decisions, and interacting with interprofessional staff. They shared that they had applied to the externship to gain additional clinical experience and that the program increased their self-confidence with respect to transitioning to the new role as RN. However, it is possible that these interviewees were highly motivated and would not have had difficulty transitioning to the RN role—this is addressed in the Limitations section of this article.

Interviewees said they initially approached VALOR with fear and apprehension but completed it feeling confident about becoming an RN. One interviewee stated, “The VALOR program gave me the confidence in my own abilities, so I was not scared and had confidence that, yes, I could do this job.” Another said, “Honestly, the entire externship program, regardless of which question you ask, my answer is going to always fall back on confidence. I became prepared for the RN job, I feel, before I graduated because of the [externship] experiences.”

Transitioning to RN Role

Transitioning involved understanding the RN’s scope of practice and feeling clinically competent. Students worked 40 hours a week over the summer and gained firsthand insight into working as an RN daily. Interviewees believed completing the externship made it easy to transition to the RN role because they knew what to expect.

Working side-by-side with nurses, students gained insight into RNs’ responsibilities and scope of practice. Interviewees reported that, after the externship, they had a better understanding of their patient care and licensure legal responsibilities.

Students began to feel clinically competent during the externship. Interviewees shared that they had had several opportunities to practice basic skills, such as giving injections. One interviewee said, “I don’t think I tried to stick a single IV when I was in school or in clinical [training].” Interviewees also commented that repeatedly practicing skills increased their self-confidence.

Students also gained firsthand insight into working with veterans and their families. During the externship, they learned about communicating therapeutically, providing education for caregivers, and advocating for patients and their families. Before the externship, they felt apprehensive about communicating with patients. One interviewee said that after the program, “Eventually you had to talk to patients, and eventually figured it out that it wasn’t so scary.”

Students found that patients were not always happy with their care, and procedures did not always go as planned. They also discovered that education did not end with the patient; family members needed education as well. The externship experience heightened students’ awareness of the RN’s role as patient advocate. One interviewee explained it is the RN’s responsibility to intervene on the patient’s behalf. Interviewees were surprised that patients would not tell their health care provider that they did not understand what was said or that they wanted another course of treatment.

The externship helped decrease learning-related stress. Interviewees indicated they had learned without fear of reprisal. One described feeling free to learn: “Uninhibited learning...you can ask what you need to without fear of not graduating.” Externship students were able to focus on learning the RN role without worrying about the next test or grade. They felt free to ask questions without fear of failing their clinical rotation.

The supportive and nurturing relationships that students developed in VALOR also increased their confidence when transitioning to the RN role. One interviewee said, “There was never the sense of, no, you learn my way, or I don’t want you here.” Interviewees shared that they felt comfortable and supported.

Decision Making

Interviewees reported that after VALOR, it was easy to make decisions regarding nursing practice, delegation, care prioritization, and career choice. As students, they found the school clinical setting did not provide the decision-making opportunities VALOR did, and they quickly realized nursing practice involved more than making patient-care decisions. One interviewee said, “In a classroom, a picture is painted of an idealistic environment that may not truly mimic the hospital unit.”

Students became familiar with the practice of delegating care to the appropriate staff and the next shift. One interviewee said VALOR “provided me with a better understanding of delegation in my RN role.” VALOR participants discovered that, as new nurses, they were less anxious when delegating to others.

Before RN licensure, VALOR participants learned about prioritizing patient care. One interviewee said, “It’s like everybody has to be charted on, and all the medications have to be passed out, but it’s a matter of getting everything done while doing the more important and more dire things first.” Students learned that all aspects of nursing are important, but they had to make rational decisions.

Interacting With Professionals

Interviewees who had been in VALOR said interacting with interprofessional (different disciplines) staff contributed to their working comfortably in teams and collaborating with others. Their collaborative relationships with physicians would help them later, when as new graduate nurses they again needed to work together with doctors. Typical comments were, “When I started as an RN, I felt I was not new at it because I had communicated with doctors in the externship program.”

Discussion

The present study found that nursing students who had been in the VALOR externship felt confident in their clinical skills when they were transitioning to the RN role. Other studies similarly have found that externship students were self-confident assuming the RN role, owing to their additional clinical experience.^12,28 The VALOR program allows students to work alongside nurses and receive hands-on experience while interacting with interprofessional health care teams. Findings of Nuttall’s quantitative study contradict those of the present, qualitative study. Nuttall used surveys and a control group, whereas this phenomenologic study captured the essence of study participants’ experiences through interviews.

The RNs interviewed in the present study discovered that, unlike nursing school, VALOR provided a realistic view of full-time work as an RN. This finding aligns with Starr and Conley’s finding that, before participating in an externship, most students were unaware of the extent of RNs’ roles and responsibilities, whereas after the program they understood these roles and responsibilities better.²⁸

The interviewees in this study thought VALOR improved their skills in communicating with patients, families, and interprofessional team members. Interviewees shared that they learned patient advocacy skills and that, through firsthand experience, realized nurses provide patients with a voice. Externships can help new graduate nurses become better communicators and can teach students the importance of patient communication and advocacy.¹²

This study also found that students wanted more exposure to realistic nursing environments, additional nursing skills practice, and more interaction with interprofessional team members. VALOR helped bridge the theory–practice gap by providing real-world nursing experience outside the academic environment and extra time for nursing skills development. In a study by Casey and colleagues, students indicated that the time allowed for nursing skills practice during school was inadequate.⁶

The VALOR program helped students learn about delegating work, whereas nursing school did not provide the opportunity to practice delegation. Other studies have corroborated that students do not practice delegation during nursing school clinical time.^29,30

Study respondents noted they could focus on learning without the fear of passing their clinical rotation. They felt supported by staff and were comfortable asking questions. White suggested that externship students who feel supported by nursing staff are able to focus on patients instead of on their discomfort.¹³ Rush and colleagues found that constraints on the student experience in traditional academic clinical rotations were replaced with “freedom and fearlessness in learning” in externships.³¹

Ten of the 12 study participants applied for a new graduate nurse position at the VAMC where they had their externship. A potential benefit to organizations that sponsor a nursing externship is the recruitment of new graduate nurses.¹⁴ Before applying for a full-time position, VALOR students had the opportunity to become familiar with the work environment and assess their fit with the employer. One student found staff nurse work “scary” and “stressful” and decided against it. She said the VALOR externship helped her realize exactly what nursing entailed: “Until this experience, I did not realize I would not like the hospital environment. This was a reality check for me.” Another student decided that working different shifts and working holidays would be difficult for her. These 2 students’ externship experience convinced them to seek other nursing positions.

Limitations

All participants in this study were nurses with excellent academic grades. It is possible they were highly motivated and might not have had any difficulty transitioning to the RN role. The principal investigator in this study was a VALOR program coordinator who knew 3 of the study participants—a potential source of bias. It is possible participants did not want to speak negatively about the program for several reasons: the interviewer was their coordinator, they received a salary during the externship, and several worked for the VA at the time of the survey.

Researchers have acknowledged the likelihood that not all VALOR students have positive experiences. It is possible that students with negative experiences did not discuss them or did not participate in the study. Increasing the size of the study sample may have brought in students with negative experiences. There is also the possibility of researcher misinterpretation and bias. Although bracketing was used, it was not possible to eliminate all potential sources of bias from this qualitative study.

Future Research

This is 1 of only 2 studies on the VALOR externship. Given the contradictory findings of these studies—Nuttall reported VALOR experience did not affect students’ transition to the RN role,³ whereas in the present study VALOR students thought the program positively affected their successful transition—additional quantitative and qualitative research is needed.

In addition, the low recruitment rate of VALOR students should be compared with other studies’ recruitment rates. The 38% VALOR extern recruitment rate for the period 2007 to 2012 is lower than the rate for other programs (G. Fuller, August 27, 2014, e-mail communication). The VALOR program does not track retention of participants after employment. Longitudinal studies should compare VALOR participants’ length of employment with that of nonparticipants’.

Conclusion

Externships provide clinical experience outside the classroom, expose students to the realities of nursing practice before graduation, and serve as a recruitment tool for hospitals. These programs, in conjunction with school-based practicums, increase exposure to the clinical environment. Before graduation, students have the opportunity to practice skills, interact with interprofessional staff, and experience different hospital units, all of which contribute to career decisions. The present study found that the VALOR externship helped new graduate nurses with their transition to the workplace. However, it is important to recognize the limitations of this study.

Interviewees indicated they were confident when they were transitioning to their new nurse role and caring for patients before receiving their RN licensure. New graduate nurses discovered they acclimated to the hospital environment quicker. The reality of working day-to-day in a hospital setting allowed students to select a compatible work environment and understand the daily challenges health care professionals encounter. Interviewees shared that they felt “like the RN” during the externship, which lessened the shock of actually assuming the RN role.

Van Manen asserted there is no conclusion or ending to a phenomenological study.²⁶ Continued research on hospital-based externships will demonstrate how these programs can assist in the development of new graduate nurses, ease their transition to practice, and benefit nursing education, practice, research, and public policy.

Learning to play a musical instrument provides a peaceful retreat from the pressures of daily life. Therapeutic outcomes of playing music include better communication skills, improved emotional release, and decreased anxiety and agitation.¹ Musical training promotes cognitive function, mental health, and a connection to others.^2,3

Depression

Impacting 14.8 million people, depression is the most prevalent mental health issue for adults aged ≥ 55 years and accounts for 10% of all medical disability in the U.S. and Canada.^4-6 About half the people diagnosed with depression also have an anxiety disorder, which can lead to smoking, drinking alcohol, overeating, and complicated health care issues.⁵ By 2020, depression is predicted to be the second most common disease in the world and cost employers about $23 billion in absenteeism.⁴

Hays and Minichiello found that learning to read music and play the piano might enhance mood and certain aspects of the quality of living indicators in older adults. Those aged ≥ 65 years who participated in playing music reported improved self-esteem, greater independence, and fewer feelings of isolation. In addition, playing music created a temporary escape from the stress of daily life.⁷ Seinfield and colleagues compared a piano training group with a control group (nonplaying) and found that those who played piano experienced a decrease in psychological distress, depression, and fatigue.⁸ Playing an instrument can positively impact the well-being of older adults throughout life by promoting empowerment, autonomy, and social cohesion.^7-11Manalai and colleagues found that a single episode of playing the piano was beneficial for a 91-year-old female patient who previously played when she was young and who was currently experiencing psychotic and depressive symptoms. Following playing, the patient’s vocabulary and insight temporarily improved. For the first time since her admission, the patient provided many details about her past mental and physical health. Even though the patient never played again, due to her delusional disorder, the improvement in mood and cognition were sustained for several months.¹² The researchers noted that the patient’s temporary improvement may have been attributed to other factors.¹²

Another study measured levels of anxiety, depression, and loneliness in senior citizens. Study participants who regularly participated in a keyboard class were less anxious, depressed, and lonely compared with the control group.¹³ Other studies support the idea that music can modulate emotional responses and enhance cognitive performance.^14,15

Mind Stimulation

As people age, they will experience progressive physiologic losses in function, such as auditory, cognition, memory, and motor control.^16,17 Affect or mood can also be impacted.⁸ Consequently, there is a focus on promoting nonpharmacologic solutions that protect against age-related health issues. For example, musical training for adults that involves sensorimotor practice produces greater changes in the auditory cortex than does the equivalent experience involving only auditory training.¹⁸ Research indicates that age-related auditory decline can be mitigated by musical training.¹⁹ Evidence also supports cognitive stimulation, which may help reduce the likelihood of cognitive impairments in advanced age.^16,17

The brain works on a principle of “use it or lose it.” Therefore, exercising the brain is important, and musical training may fill that need. Learning a skill such as playing an instrument reorganizes the brain’s neural pathways.^2,16 Brain plasticity is the ability of the brain to change its structure, and engaging older adults in sensory, cognitive, and motor activities creates positive outcomes.^16,17 Research also indicates active participation in music lessons creates larger plasticity effects than does passively listening to music.¹⁶ Musical training provides a multisensory activity that requires integrating signals from different sensory modalities with motor responses.¹⁶ Verghese and colleagues found that individuals who played a musical instrument were less likely to experience dementia than were those whose leisure activities consisted of reading, writing, and working crossword puzzles.²⁰ Verghese suggested that 6 months of piano lessons in older adults improved the brain’s executive functioning (regulates abilities and behaviors) and working memory (ie, keeping track of information).²⁰ Balbag and colleagues who conducted a study of twins found that “playing an instrument in older adulthood is significantly associated with reduced likelihood of dementia and cognitive impairment.”²¹ Musical training is also associated with improved visual memory and the ability to divide the individual’s attention between several activities. This ability is crucial for activities such as driving and is useful for navigating crowded areas, such as a mall.^22,23

Dexterity

Musical training also has been found to be beneficial for stroke survivors, because this type of training elicits a change in the reorganization of the sensorimotor cortex that results in improved movement quality.²⁴ Piano playing can lead to meaningful improvements in manual dexterity, finger movement coordination, and functional use of upper extremities.²⁵

Zelazny studied the effects of keyboard playing on 4 older adults with osteoarthritis who over 4 weeks had 30-minute sessions of electronic keyboard playing 4 days per week.²⁶ The researcher found that participants reported decreased arthritic pain, increased dexterity, and increased finger strength. Playing the piano requires both eye and hand coordination, which is essential as a person ages. Improved dexterity of fine motor skills can assist individuals with the activities of daily living, such as buttoning a shirt and using a remote control.²⁶

Stress Reduction

Life is filled with stressors, and anyone can have difficulty coping with daily stress. According to Toyoshima and colleagues, playing the piano can lower cortisol levels and decrease a person’s anxiety level.²⁷ These researchers compared the activities of piano playing, calligraphy, and clay molding and found that playing the piano was significantly more effective at lowering stress levels when measuring salivary C-reactive protein levels and State-Trait Anxiety Inventory (STAI) scores.

Another study found stress reduction was significant for participants who played the keyboard compared with participants who relaxed, read magazines, or solved puzzles.²⁸ Stress has a negative impact on the immune system, which can increase an individual’s risk of disease. According to Mohd “emotional stress is a major contributing factor to the 6 leading causes of death in the U.S.: cancer, coronary heart disease, accidental injuries, respiratory disorders, cirrhosis of the liver, and suicide.”²⁹

PTSD and Guitars for Vets Program

Guitars for Vets is a nonprofit organization with 25 chapters that uses music to assist veterans with physical and mental health injuries.³⁰ The program provides free guitars and weekly music lessons taught by volunteers. The weekly music lessons create a forum for veterans to socialize and share personal experiences, thus contributing to their healing process.³⁰ A randomized, controlled pilot study was conducted with veterans diagnosed with posttraumatic stress disorder (PTSD) who may have physical and mental changes such as self-isolation from others, night sweats, flashbacks, and depression.³¹

The study participants had weekly private guitar lessons for 1 hour and a group learning session. The results showed positive outcomes in both PTSD and depression symptoms after 6 weeks of guitar lessons.³⁰ One veteran with PTSD who participated in the Guitar for Vets Program stated, “I came here with some real serious anger issues; this takes my mind off everything.” This veteran noted that as he practiced, a peaceful feeling enveloped him and the memories of trauma faded.³²

Personal Experience

Following the completion of my PhD, I started piano lessons as a hobby. I also found engaging in playing music helped me to psychologically cope with the overwhelming stress of having a parent with a debilitating disease.

My dad was diagnosed with Parkinson disease, making it difficult for him to view life positively. Piano lessons helped him to mentally deal with his disease. Dad genuinely looked forward to his music lessons and was able to focus on practicing the piano rather than on his disease. I believe playing the piano prevented him from becoming depressed and kept him engaged, because he was accomplishing something.

Dad’s Parkinson disease has progressed; he is now in a nursing home. My gift to Dad is playing the piano for him. I sincerely believe it helps him cope with his disease or at least temporarily forget about it. His mood changes, and he becomes more animated. In his more lucid moments, we play music together. Playing music has a magical way of creating peace within the mind. Plato is often attributed with the quote, “Music gives a soul to the universe, wings to the mind, flight to the imagination, and life to everything.”

Conclusions

A healthful lifestyle includes holistically addressing issues pertaining to mental and physical well-being. Learning how to play a musical instrument is a workout for the brain, just as physical exercise is a workout for the body; both are necessary for optimal health. Evidence exists to support the hypothesis that playing an instrument elicits brain changes that positively influence cognitive functioning and decreases stress. Despite the lifelong benefits of playing an instrument, only about 8% of adults aged > 18 years play a musical instrument.³³

Playing a musical instrument provides health benefits without the adverse effects that accompany pharmacologic therapy. It also can help improve social skills and provide individuals with a sense of achievement. Group music lessons provide an opportunity for people to build bonds and positively affect lifestyle choices.

In addition, engaging individuals in learning to play music may decrease the cost of health care when considering treatments for depression, PTSD, and substance abuse. Playing an instrument may help decrease the need for antidepressants and provide a healthy recreational activity. Based on its physical and mental benefits, learning to play a musical instrument should be explored as complementary alternative medicine. Compared with filling prescription medications over an individual’s lifetime, the cost of a portable keyboard is substantially less.

Given the benefits of increased coordination, social involvement, neural responses, and ability to focus along with improving fine motor skills and reducing stress, including music lessons as part of a veteran’s health care makes sense and is well worth further investigation and research.

Acknowledgements
The author would like to thank Jack Hooten, MHA, MSN, RN, and Jennifer Hammond, MS, for their help in preparing this manuscript.

Learning to play a musical instrument provides a peaceful retreat from the pressures of daily life. Therapeutic outcomes of playing music include better communication skills, improved emotional release, and decreased anxiety and agitation.¹ Musical training promotes cognitive function, mental health, and a connection to others.^2,3

Depression

Impacting 14.8 million people, depression is the most prevalent mental health issue for adults aged ≥ 55 years and accounts for 10% of all medical disability in the U.S. and Canada.^4-6 About half the people diagnosed with depression also have an anxiety disorder, which can lead to smoking, drinking alcohol, overeating, and complicated health care issues.⁵ By 2020, depression is predicted to be the second most common disease in the world and cost employers about $23 billion in absenteeism.⁴

Hays and Minichiello found that learning to read music and play the piano might enhance mood and certain aspects of the quality of living indicators in older adults. Those aged ≥ 65 years who participated in playing music reported improved self-esteem, greater independence, and fewer feelings of isolation. In addition, playing music created a temporary escape from the stress of daily life.⁷ Seinfield and colleagues compared a piano training group with a control group (nonplaying) and found that those who played piano experienced a decrease in psychological distress, depression, and fatigue.⁸ Playing an instrument can positively impact the well-being of older adults throughout life by promoting empowerment, autonomy, and social cohesion.^7-11Manalai and colleagues found that a single episode of playing the piano was beneficial for a 91-year-old female patient who previously played when she was young and who was currently experiencing psychotic and depressive symptoms. Following playing, the patient’s vocabulary and insight temporarily improved. For the first time since her admission, the patient provided many details about her past mental and physical health. Even though the patient never played again, due to her delusional disorder, the improvement in mood and cognition were sustained for several months.¹² The researchers noted that the patient’s temporary improvement may have been attributed to other factors.¹²

Another study measured levels of anxiety, depression, and loneliness in senior citizens. Study participants who regularly participated in a keyboard class were less anxious, depressed, and lonely compared with the control group.¹³ Other studies support the idea that music can modulate emotional responses and enhance cognitive performance.^14,15

Mind Stimulation

As people age, they will experience progressive physiologic losses in function, such as auditory, cognition, memory, and motor control.^16,17 Affect or mood can also be impacted.⁸ Consequently, there is a focus on promoting nonpharmacologic solutions that protect against age-related health issues. For example, musical training for adults that involves sensorimotor practice produces greater changes in the auditory cortex than does the equivalent experience involving only auditory training.¹⁸ Research indicates that age-related auditory decline can be mitigated by musical training.¹⁹ Evidence also supports cognitive stimulation, which may help reduce the likelihood of cognitive impairments in advanced age.^16,17

The brain works on a principle of “use it or lose it.” Therefore, exercising the brain is important, and musical training may fill that need. Learning a skill such as playing an instrument reorganizes the brain’s neural pathways.^2,16 Brain plasticity is the ability of the brain to change its structure, and engaging older adults in sensory, cognitive, and motor activities creates positive outcomes.^16,17 Research also indicates active participation in music lessons creates larger plasticity effects than does passively listening to music.¹⁶ Musical training provides a multisensory activity that requires integrating signals from different sensory modalities with motor responses.¹⁶ Verghese and colleagues found that individuals who played a musical instrument were less likely to experience dementia than were those whose leisure activities consisted of reading, writing, and working crossword puzzles.²⁰ Verghese suggested that 6 months of piano lessons in older adults improved the brain’s executive functioning (regulates abilities and behaviors) and working memory (ie, keeping track of information).²⁰ Balbag and colleagues who conducted a study of twins found that “playing an instrument in older adulthood is significantly associated with reduced likelihood of dementia and cognitive impairment.”²¹ Musical training is also associated with improved visual memory and the ability to divide the individual’s attention between several activities. This ability is crucial for activities such as driving and is useful for navigating crowded areas, such as a mall.^22,23

Dexterity

Musical training also has been found to be beneficial for stroke survivors, because this type of training elicits a change in the reorganization of the sensorimotor cortex that results in improved movement quality.²⁴ Piano playing can lead to meaningful improvements in manual dexterity, finger movement coordination, and functional use of upper extremities.²⁵

Zelazny studied the effects of keyboard playing on 4 older adults with osteoarthritis who over 4 weeks had 30-minute sessions of electronic keyboard playing 4 days per week.²⁶ The researcher found that participants reported decreased arthritic pain, increased dexterity, and increased finger strength. Playing the piano requires both eye and hand coordination, which is essential as a person ages. Improved dexterity of fine motor skills can assist individuals with the activities of daily living, such as buttoning a shirt and using a remote control.²⁶

Stress Reduction

Life is filled with stressors, and anyone can have difficulty coping with daily stress. According to Toyoshima and colleagues, playing the piano can lower cortisol levels and decrease a person’s anxiety level.²⁷ These researchers compared the activities of piano playing, calligraphy, and clay molding and found that playing the piano was significantly more effective at lowering stress levels when measuring salivary C-reactive protein levels and State-Trait Anxiety Inventory (STAI) scores.

Another study found stress reduction was significant for participants who played the keyboard compared with participants who relaxed, read magazines, or solved puzzles.²⁸ Stress has a negative impact on the immune system, which can increase an individual’s risk of disease. According to Mohd “emotional stress is a major contributing factor to the 6 leading causes of death in the U.S.: cancer, coronary heart disease, accidental injuries, respiratory disorders, cirrhosis of the liver, and suicide.”²⁹

PTSD and Guitars for Vets Program

Guitars for Vets is a nonprofit organization with 25 chapters that uses music to assist veterans with physical and mental health injuries.³⁰ The program provides free guitars and weekly music lessons taught by volunteers. The weekly music lessons create a forum for veterans to socialize and share personal experiences, thus contributing to their healing process.³⁰ A randomized, controlled pilot study was conducted with veterans diagnosed with posttraumatic stress disorder (PTSD) who may have physical and mental changes such as self-isolation from others, night sweats, flashbacks, and depression.³¹

The study participants had weekly private guitar lessons for 1 hour and a group learning session. The results showed positive outcomes in both PTSD and depression symptoms after 6 weeks of guitar lessons.³⁰ One veteran with PTSD who participated in the Guitar for Vets Program stated, “I came here with some real serious anger issues; this takes my mind off everything.” This veteran noted that as he practiced, a peaceful feeling enveloped him and the memories of trauma faded.³²

Personal Experience

Following the completion of my PhD, I started piano lessons as a hobby. I also found engaging in playing music helped me to psychologically cope with the overwhelming stress of having a parent with a debilitating disease.

My dad was diagnosed with Parkinson disease, making it difficult for him to view life positively. Piano lessons helped him to mentally deal with his disease. Dad genuinely looked forward to his music lessons and was able to focus on practicing the piano rather than on his disease. I believe playing the piano prevented him from becoming depressed and kept him engaged, because he was accomplishing something.

Dad’s Parkinson disease has progressed; he is now in a nursing home. My gift to Dad is playing the piano for him. I sincerely believe it helps him cope with his disease or at least temporarily forget about it. His mood changes, and he becomes more animated. In his more lucid moments, we play music together. Playing music has a magical way of creating peace within the mind. Plato is often attributed with the quote, “Music gives a soul to the universe, wings to the mind, flight to the imagination, and life to everything.”

Conclusions

A healthful lifestyle includes holistically addressing issues pertaining to mental and physical well-being. Learning how to play a musical instrument is a workout for the brain, just as physical exercise is a workout for the body; both are necessary for optimal health. Evidence exists to support the hypothesis that playing an instrument elicits brain changes that positively influence cognitive functioning and decreases stress. Despite the lifelong benefits of playing an instrument, only about 8% of adults aged > 18 years play a musical instrument.³³

Playing a musical instrument provides health benefits without the adverse effects that accompany pharmacologic therapy. It also can help improve social skills and provide individuals with a sense of achievement. Group music lessons provide an opportunity for people to build bonds and positively affect lifestyle choices.

In addition, engaging individuals in learning to play music may decrease the cost of health care when considering treatments for depression, PTSD, and substance abuse. Playing an instrument may help decrease the need for antidepressants and provide a healthy recreational activity. Based on its physical and mental benefits, learning to play a musical instrument should be explored as complementary alternative medicine. Compared with filling prescription medications over an individual’s lifetime, the cost of a portable keyboard is substantially less.

Given the benefits of increased coordination, social involvement, neural responses, and ability to focus along with improving fine motor skills and reducing stress, including music lessons as part of a veteran’s health care makes sense and is well worth further investigation and research.

Acknowledgements
The author would like to thank Jack Hooten, MHA, MSN, RN, and Jennifer Hammond, MS, for their help in preparing this manuscript.

Learning to play a musical instrument provides a peaceful retreat from the pressures of daily life. Therapeutic outcomes of playing music include better communication skills, improved emotional release, and decreased anxiety and agitation.¹ Musical training promotes cognitive function, mental health, and a connection to others.^2,3

Depression

Impacting 14.8 million people, depression is the most prevalent mental health issue for adults aged ≥ 55 years and accounts for 10% of all medical disability in the U.S. and Canada.^4-6 About half the people diagnosed with depression also have an anxiety disorder, which can lead to smoking, drinking alcohol, overeating, and complicated health care issues.⁵ By 2020, depression is predicted to be the second most common disease in the world and cost employers about $23 billion in absenteeism.⁴

Hays and Minichiello found that learning to read music and play the piano might enhance mood and certain aspects of the quality of living indicators in older adults. Those aged ≥ 65 years who participated in playing music reported improved self-esteem, greater independence, and fewer feelings of isolation. In addition, playing music created a temporary escape from the stress of daily life.⁷ Seinfield and colleagues compared a piano training group with a control group (nonplaying) and found that those who played piano experienced a decrease in psychological distress, depression, and fatigue.⁸ Playing an instrument can positively impact the well-being of older adults throughout life by promoting empowerment, autonomy, and social cohesion.^7-11Manalai and colleagues found that a single episode of playing the piano was beneficial for a 91-year-old female patient who previously played when she was young and who was currently experiencing psychotic and depressive symptoms. Following playing, the patient’s vocabulary and insight temporarily improved. For the first time since her admission, the patient provided many details about her past mental and physical health. Even though the patient never played again, due to her delusional disorder, the improvement in mood and cognition were sustained for several months.¹² The researchers noted that the patient’s temporary improvement may have been attributed to other factors.¹²

Another study measured levels of anxiety, depression, and loneliness in senior citizens. Study participants who regularly participated in a keyboard class were less anxious, depressed, and lonely compared with the control group.¹³ Other studies support the idea that music can modulate emotional responses and enhance cognitive performance.^14,15

Mind Stimulation

As people age, they will experience progressive physiologic losses in function, such as auditory, cognition, memory, and motor control.^16,17 Affect or mood can also be impacted.⁸ Consequently, there is a focus on promoting nonpharmacologic solutions that protect against age-related health issues. For example, musical training for adults that involves sensorimotor practice produces greater changes in the auditory cortex than does the equivalent experience involving only auditory training.¹⁸ Research indicates that age-related auditory decline can be mitigated by musical training.¹⁹ Evidence also supports cognitive stimulation, which may help reduce the likelihood of cognitive impairments in advanced age.^16,17

The brain works on a principle of “use it or lose it.” Therefore, exercising the brain is important, and musical training may fill that need. Learning a skill such as playing an instrument reorganizes the brain’s neural pathways.^2,16 Brain plasticity is the ability of the brain to change its structure, and engaging older adults in sensory, cognitive, and motor activities creates positive outcomes.^16,17 Research also indicates active participation in music lessons creates larger plasticity effects than does passively listening to music.¹⁶ Musical training provides a multisensory activity that requires integrating signals from different sensory modalities with motor responses.¹⁶ Verghese and colleagues found that individuals who played a musical instrument were less likely to experience dementia than were those whose leisure activities consisted of reading, writing, and working crossword puzzles.²⁰ Verghese suggested that 6 months of piano lessons in older adults improved the brain’s executive functioning (regulates abilities and behaviors) and working memory (ie, keeping track of information).²⁰ Balbag and colleagues who conducted a study of twins found that “playing an instrument in older adulthood is significantly associated with reduced likelihood of dementia and cognitive impairment.”²¹ Musical training is also associated with improved visual memory and the ability to divide the individual’s attention between several activities. This ability is crucial for activities such as driving and is useful for navigating crowded areas, such as a mall.^22,23

Dexterity

Musical training also has been found to be beneficial for stroke survivors, because this type of training elicits a change in the reorganization of the sensorimotor cortex that results in improved movement quality.²⁴ Piano playing can lead to meaningful improvements in manual dexterity, finger movement coordination, and functional use of upper extremities.²⁵

Zelazny studied the effects of keyboard playing on 4 older adults with osteoarthritis who over 4 weeks had 30-minute sessions of electronic keyboard playing 4 days per week.²⁶ The researcher found that participants reported decreased arthritic pain, increased dexterity, and increased finger strength. Playing the piano requires both eye and hand coordination, which is essential as a person ages. Improved dexterity of fine motor skills can assist individuals with the activities of daily living, such as buttoning a shirt and using a remote control.²⁶

Stress Reduction

Life is filled with stressors, and anyone can have difficulty coping with daily stress. According to Toyoshima and colleagues, playing the piano can lower cortisol levels and decrease a person’s anxiety level.²⁷ These researchers compared the activities of piano playing, calligraphy, and clay molding and found that playing the piano was significantly more effective at lowering stress levels when measuring salivary C-reactive protein levels and State-Trait Anxiety Inventory (STAI) scores.

Another study found stress reduction was significant for participants who played the keyboard compared with participants who relaxed, read magazines, or solved puzzles.²⁸ Stress has a negative impact on the immune system, which can increase an individual’s risk of disease. According to Mohd “emotional stress is a major contributing factor to the 6 leading causes of death in the U.S.: cancer, coronary heart disease, accidental injuries, respiratory disorders, cirrhosis of the liver, and suicide.”²⁹

PTSD and Guitars for Vets Program

Guitars for Vets is a nonprofit organization with 25 chapters that uses music to assist veterans with physical and mental health injuries.³⁰ The program provides free guitars and weekly music lessons taught by volunteers. The weekly music lessons create a forum for veterans to socialize and share personal experiences, thus contributing to their healing process.³⁰ A randomized, controlled pilot study was conducted with veterans diagnosed with posttraumatic stress disorder (PTSD) who may have physical and mental changes such as self-isolation from others, night sweats, flashbacks, and depression.³¹

The study participants had weekly private guitar lessons for 1 hour and a group learning session. The results showed positive outcomes in both PTSD and depression symptoms after 6 weeks of guitar lessons.³⁰ One veteran with PTSD who participated in the Guitar for Vets Program stated, “I came here with some real serious anger issues; this takes my mind off everything.” This veteran noted that as he practiced, a peaceful feeling enveloped him and the memories of trauma faded.³²

Personal Experience

Following the completion of my PhD, I started piano lessons as a hobby. I also found engaging in playing music helped me to psychologically cope with the overwhelming stress of having a parent with a debilitating disease.

My dad was diagnosed with Parkinson disease, making it difficult for him to view life positively. Piano lessons helped him to mentally deal with his disease. Dad genuinely looked forward to his music lessons and was able to focus on practicing the piano rather than on his disease. I believe playing the piano prevented him from becoming depressed and kept him engaged, because he was accomplishing something.

Dad’s Parkinson disease has progressed; he is now in a nursing home. My gift to Dad is playing the piano for him. I sincerely believe it helps him cope with his disease or at least temporarily forget about it. His mood changes, and he becomes more animated. In his more lucid moments, we play music together. Playing music has a magical way of creating peace within the mind. Plato is often attributed with the quote, “Music gives a soul to the universe, wings to the mind, flight to the imagination, and life to everything.”

Conclusions

A healthful lifestyle includes holistically addressing issues pertaining to mental and physical well-being. Learning how to play a musical instrument is a workout for the brain, just as physical exercise is a workout for the body; both are necessary for optimal health. Evidence exists to support the hypothesis that playing an instrument elicits brain changes that positively influence cognitive functioning and decreases stress. Despite the lifelong benefits of playing an instrument, only about 8% of adults aged > 18 years play a musical instrument.³³

Playing a musical instrument provides health benefits without the adverse effects that accompany pharmacologic therapy. It also can help improve social skills and provide individuals with a sense of achievement. Group music lessons provide an opportunity for people to build bonds and positively affect lifestyle choices.

In addition, engaging individuals in learning to play music may decrease the cost of health care when considering treatments for depression, PTSD, and substance abuse. Playing an instrument may help decrease the need for antidepressants and provide a healthy recreational activity. Based on its physical and mental benefits, learning to play a musical instrument should be explored as complementary alternative medicine. Compared with filling prescription medications over an individual’s lifetime, the cost of a portable keyboard is substantially less.

Given the benefits of increased coordination, social involvement, neural responses, and ability to focus along with improving fine motor skills and reducing stress, including music lessons as part of a veteran’s health care makes sense and is well worth further investigation and research.

Acknowledgements
The author would like to thank Jack Hooten, MHA, MSN, RN, and Jennifer Hammond, MS, for their help in preparing this manuscript.