Jack Hooten, RN, MSN, MHA

The VA Learning Opportunity Residency (VALOR) program is a prelicensure experience with a nurse preceptor for rising senior students enrolled in a bachelor of science in nursing program. Students must have a minimum 3.0 grade-point average to apply. The program provides 800 hours of paid learning experiences in diverse didactic and hands-on clinical situations. The first 400 hours of the program (10 weeks) occur over the summer, and the second 400 hours take place during the fall and spring semesters of the student’s last year of school.¹ During the last 400 hours, students are placed in the areas they are interested in working as new graduate nurses.

The aim of the Salem VALOR program is to develop the next generation of VAMC nurses by recruiting new graduate nurses. The Salem VAMC structures the VALOR program to meet the needs of both the students and the facility. According to Glenda Fuller, the student programs manager for the VA, national VALOR retention rates from 2007 to 2011 have averaged 38%. However, more applicants apply for new graduate nurse positions than are available. Included in the VHA Directive 2011-039, facilities that hire a nurse with ≤ 1 year of experience must enroll them in a yearlong transition-to-practice program.² Therefore, facilities may limit the number of new graduate nurse positions.

On entry into the VALOR program, participants write a journal entry regarding their fears and concerns about becoming a new graduate nurse. In addition, each student turns in a written reflection about their experiences each week and participates in daily group discussions with the program coordinator. The last day of the summer portion of the program, students again write about their fears and concerns about becoming a new graduate nurse. After reviewing the VALOR journals, conducting focus groups, and taking notes during the daily meetings, the authors describe the following VALOR experience from the summer of 2013 at the Salem VAMC.

Preparing New Graduates

Hospitals are under pressure to provide high-quality nursing care despite hiring new graduate nurses who are unfamiliar and inexperienced in caring for patients’ complex health care needs. New graduate nurses currently make up more than 10% of hospital nursing staff, and that number is expected to grow as baby boomers retire.³ Boswell and colleagues suggest that those new graduate nurses are unprepared for the registered nurse role.⁴ Identifying strategies to facilitate the transition from student to the new graduate nurse role will likely decrease attrition rates and increase the effectiveness and the quality of patient care. Nursing programs, such as the VALOR, can ease the transition from the classroom to the working environment.⁵

This result is evident when observing how VALOR students enhance their nursing skills after the 10-week summer program. VALOR participant Andrea King published her summer experience at the Salem VAMC in The Torch, the Virginia Nursing Students’ Association newsletter.⁶ “I had so much practice and eventually confidence in my nursing skills,” she wrote, “that I had the autonomy and independence to feel like I was working as an actual nurse.”⁶

The VALOR Experience

During the summer months, senior nursing students have the opportunity to go on rounds with the chaplain, work with nurse practitioners, attend outings with mental health patients, participate in home health visits, interact with patients in groups, and rotate to different hospital units. Students attend FranklinCovey classes (which specialize in employee performance improvement), participate in an evidence-based practice (EBP) project (which helps them to learn about teamwork), and collaborate with interdisciplinary health care professionals. At the end of the summer, students present their team EBP project to the nurse executive committee. Presentation experience assists students in acquiring public speaking skills. Students are nervous about presenting to a room full of executives. However, they learn to depend on one another and to strengthen weaknesses and build on strengths.

When high-performing students come together as one cohort, this dynamic poses challenges for the VALOR participants. One student described her vulnerability in relation to her VALOR peers as “the hardest hit to my self-confidence has been working with such intelligent and accomplished cohorts.” Another student found that even though she was at the top of her class, working with the other VALORs “challenged her self-confidence” because all the program participants were high-performing students. She found it pushed her to perform better. One person reflected, “I feel the VALOR experience has really given all of us the opportunity to unleash our full potential. I have no doubt that these students will become future health care leaders.”

Building Skills

Learning new skills and interacting with physicians are stressful experiences for new graduate nurses.⁷ A study by Casey and colleagues suggests that new graduate nurses feel inadequate and lack self-confidence.⁸ VALOR participants share these concerns. The initial journal entries revealed fears of making a mistake, harming patients, fitting in to the work culture, working with doctors, feeling anxious about patient interactions, and performing clinical skills competently.

Initially, students focused on needing extensive practice with nursing skills as evidenced by one student’s comments, “I’m honestly concerned about some of the procedures; I’ve only put in 3 IVs during nursing school, I am not confident walking in to a room and performing a procedure on my own. I would be overwhelmed.” When considering RN-to-MD communication, one student commented, “I’m nervous, doctors can be very hard on new nurses, I’ve witnessed this over and over.”

During the first weeks, the participants discussed the fear of being “on their own” without the benefit of their instructor once they graduate. One person noted this feeling as “The seed of fear grows as graduation approaches.” This lack of self-confidence and feeling scared is a consistent issue with all the VALOR students the first day of the program.

During the program, VALOR students developed nursing skills and became certified in advanced cardiac life support (ACLS). One student suggested that the ACLS class was a great team builder and instilled confidence among the VALOR participants. Another student shared, “We all agreed that attaining this certification was a culmination of our overall VA experience.” A student who was working in an acute care area applied the newly learned ACLS skills the following week when a patient coded. The student’s journal reflected how preparation makes a difference and described his experience and knowing how to react as “powerful.”

The Reality of Nursing

The VALOR program helps connect the academic environment with the realities of the workplace. Wilson found bridging the theory-practice gap between school and workplace improves learning opportunities for students.⁹ Wilson also suggests that having peers to identify with helps to bridge the theory-practice gap.⁹ Journal entries reflected “the perfect hospital” of textbooks was different from working every day and “almost being a nurse.” During the VALOR program, students immerse themselves in the realistic nursing environment of staff shortages, equipment unavailability, disgruntled patients, and peer-to-peer communication that is not always civil. The 40-hour workweek provides a realistic hands-on view of nursing and introduces students to socializing as a nurse and the nursing work culture.

After the 2013 summer portion of the program, students were able to differentiate between the realities of the world of health care and the academic view of the health care environment. As students progressed over the summer, a noticeable transformation took place. The student who wrote about needing more skills practice on day 1 found that she was comfortable with injections, hanging IVs, and providing patient care at the end of week 3. Students grew more comfortable collaborating with doctors and other interdisciplinary professionals. They also became competent with basic nursing skills and had a realistic view of the nursing world.

In addition, students became aware of the emotional aspects of nursing. One student discussed making a difference in a veteran’s life after participating in a substance abuse group. “While I was on my way home I started thinking about those vets and their stories, and I started getting emotional. I just felt bad that after doing the great deed of fighting for our country that they became victims of substance abuse,” the student explained. “That afternoon, as I departed the vets, I left hopeful and realized I could make a difference in the life of a veteran.” Another student perceived that doctors were discussing a veteran’s terminal lung cancer “nonchalantly” and reflected, “though I do recognize that a certain degree of disconnection must take place, a certain measure of empathy must remain at all times to effect positive outcomes in the patient’s health.”

VALOR students noted that the program gave them exposure to different areas of nursing. This experience assisted them in deciding on an area of nursing interest. One student who always wanted to be an emergency department nurse found that after that rotation, she was not “cut out to be an emergency department nurse.” Some students came into the program thinking they knew precisely what they wanted to do following graduation, but found a new interest.

Daily Debriefings

Through daily debriefing discussions, students learn about best practices, patient advocacy, nursing leadership, and communication skills. Some have said that it has helped them “get through the day” knowing they had an outlet to review their experiences with VALOR peers. Discussions focus on both the positive and negative aspects of their day.

Students found that group discussions bonded them as a team and allowed them to share their feelings openly. One student found, “What really impacted me was just the amount of learning I received from my VALOR friends.” The group discussions and projects allow students who may typically work in isolation to come together as a team, providing a safe outlet for reflection and self-expression. Meeting daily with peers to share personal experiences increases team cohesion. Research suggests that students learn from their peers.^10,11 Working closely with these students, the benefit of peer-to-peer learning was obvious. Students support and teach one another in a nonthreatening environment, which enhances their learning process.

End of the Summer Journey

For the students’ final journal entry, they are asked to identify their greatest fear from week 1 and describe how that has changed by week 10. Journal entries indicated that the students were no longer afraid of being a new nurse, and doctors were “not so scary anymore.” Students already know that nursing is not “going to be peachy,” but participating in the VALOR program allayed their worst fears. One student wrote, “When I had the experiences of doctors, dieticians, and physical therapists asking me questions about my patient and taking what I said seriously, it really boosted my confidence.”

Students seemed less nervous taking on the new graduate nurse role, because they practiced skills and experienced the real life of a nurse. The student who was worried about starting IVs stated, “It is second nature now.” The student who was worried about talking to doctors is now paging and communicating with them in teams. “I feel that I’m more likely to converse with other members of the health care team because of this experience,” one student reported. Another student experienced being afraid of practicing clinical skills because of her lack of experience. “I had put in only 3 IVs previously. I had never seen a cardiac catheterization,” she related.  “I had never run an electrocardiography (EKG), and I had never had an opportunity to see many of the things I have seen. I was afraid of taking a full patient load, and I was apprehensive about simple things such as hanging IV medications. I was unsure of myself, and desperately needed practice. I lacked confidence, and needed to gain experience. Now, looking back, those things seem silly.”

Coming out of this program, one student suggested, “I have found that my expectations were blown away.” The 2013 cohort walked away from the summer portion of the program with ACLS training, EKG classes, interdisciplinary team experiences, FranklinCovey personal development seminars, and most of all, hands-on experience that provided these future nurses with confidence in their abilities. Participants felt that after this summer they would be “a step ahead” of their peers when they returned to school in the fall. One student related, after returning to school, “My professor asked me to help teach an EKG class since I was ACLS certified.”

Conclusion

The goal of sharing the VALOR program and students’ experiences at the Salem VAMC is to highlight how students grow clinically and professionally. The program is not a single-person endeavor. The chief nurse executive, managers, interdisciplinary health care professionals, and nursing preceptors support the program. Gaining stakeholder buy-in for the program results in positive experiences for both students and veterans.

Taking top-performing students and grouping them as a cohort creates a learning experience for students and benefits the facility. Students develop essential nursing skills, which assist their transition to the new graduate nurse role. In the words of one student, “As this experience comes to a close, I find myself increasingly apprehensive of finishing. The VALOR position has been like a dream come true for me. I have developed as a person and a future nurse.” As the new generation of nurses, the VALORs provide the institution with fresh eyes and new ideas on how to improve the system and to care for our nation’s veterans.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

The VA Learning Opportunity Residency (VALOR) program is a prelicensure experience with a nurse preceptor for rising senior students enrolled in a bachelor of science in nursing program. Students must have a minimum 3.0 grade-point average to apply. The program provides 800 hours of paid learning experiences in diverse didactic and hands-on clinical situations. The first 400 hours of the program (10 weeks) occur over the summer, and the second 400 hours take place during the fall and spring semesters of the student’s last year of school.¹ During the last 400 hours, students are placed in the areas they are interested in working as new graduate nurses.

The aim of the Salem VALOR program is to develop the next generation of VAMC nurses by recruiting new graduate nurses. The Salem VAMC structures the VALOR program to meet the needs of both the students and the facility. According to Glenda Fuller, the student programs manager for the VA, national VALOR retention rates from 2007 to 2011 have averaged 38%. However, more applicants apply for new graduate nurse positions than are available. Included in the VHA Directive 2011-039, facilities that hire a nurse with ≤ 1 year of experience must enroll them in a yearlong transition-to-practice program.² Therefore, facilities may limit the number of new graduate nurse positions.

On entry into the VALOR program, participants write a journal entry regarding their fears and concerns about becoming a new graduate nurse. In addition, each student turns in a written reflection about their experiences each week and participates in daily group discussions with the program coordinator. The last day of the summer portion of the program, students again write about their fears and concerns about becoming a new graduate nurse. After reviewing the VALOR journals, conducting focus groups, and taking notes during the daily meetings, the authors describe the following VALOR experience from the summer of 2013 at the Salem VAMC.

Preparing New Graduates

Hospitals are under pressure to provide high-quality nursing care despite hiring new graduate nurses who are unfamiliar and inexperienced in caring for patients’ complex health care needs. New graduate nurses currently make up more than 10% of hospital nursing staff, and that number is expected to grow as baby boomers retire.³ Boswell and colleagues suggest that those new graduate nurses are unprepared for the registered nurse role.⁴ Identifying strategies to facilitate the transition from student to the new graduate nurse role will likely decrease attrition rates and increase the effectiveness and the quality of patient care. Nursing programs, such as the VALOR, can ease the transition from the classroom to the working environment.⁵

This result is evident when observing how VALOR students enhance their nursing skills after the 10-week summer program. VALOR participant Andrea King published her summer experience at the Salem VAMC in The Torch, the Virginia Nursing Students’ Association newsletter.⁶ “I had so much practice and eventually confidence in my nursing skills,” she wrote, “that I had the autonomy and independence to feel like I was working as an actual nurse.”⁶

The VALOR Experience

During the summer months, senior nursing students have the opportunity to go on rounds with the chaplain, work with nurse practitioners, attend outings with mental health patients, participate in home health visits, interact with patients in groups, and rotate to different hospital units. Students attend FranklinCovey classes (which specialize in employee performance improvement), participate in an evidence-based practice (EBP) project (which helps them to learn about teamwork), and collaborate with interdisciplinary health care professionals. At the end of the summer, students present their team EBP project to the nurse executive committee. Presentation experience assists students in acquiring public speaking skills. Students are nervous about presenting to a room full of executives. However, they learn to depend on one another and to strengthen weaknesses and build on strengths.

When high-performing students come together as one cohort, this dynamic poses challenges for the VALOR participants. One student described her vulnerability in relation to her VALOR peers as “the hardest hit to my self-confidence has been working with such intelligent and accomplished cohorts.” Another student found that even though she was at the top of her class, working with the other VALORs “challenged her self-confidence” because all the program participants were high-performing students. She found it pushed her to perform better. One person reflected, “I feel the VALOR experience has really given all of us the opportunity to unleash our full potential. I have no doubt that these students will become future health care leaders.”

Building Skills

Learning new skills and interacting with physicians are stressful experiences for new graduate nurses.⁷ A study by Casey and colleagues suggests that new graduate nurses feel inadequate and lack self-confidence.⁸ VALOR participants share these concerns. The initial journal entries revealed fears of making a mistake, harming patients, fitting in to the work culture, working with doctors, feeling anxious about patient interactions, and performing clinical skills competently.

Initially, students focused on needing extensive practice with nursing skills as evidenced by one student’s comments, “I’m honestly concerned about some of the procedures; I’ve only put in 3 IVs during nursing school, I am not confident walking in to a room and performing a procedure on my own. I would be overwhelmed.” When considering RN-to-MD communication, one student commented, “I’m nervous, doctors can be very hard on new nurses, I’ve witnessed this over and over.”

During the first weeks, the participants discussed the fear of being “on their own” without the benefit of their instructor once they graduate. One person noted this feeling as “The seed of fear grows as graduation approaches.” This lack of self-confidence and feeling scared is a consistent issue with all the VALOR students the first day of the program.

During the program, VALOR students developed nursing skills and became certified in advanced cardiac life support (ACLS). One student suggested that the ACLS class was a great team builder and instilled confidence among the VALOR participants. Another student shared, “We all agreed that attaining this certification was a culmination of our overall VA experience.” A student who was working in an acute care area applied the newly learned ACLS skills the following week when a patient coded. The student’s journal reflected how preparation makes a difference and described his experience and knowing how to react as “powerful.”

The Reality of Nursing

The VALOR program helps connect the academic environment with the realities of the workplace. Wilson found bridging the theory-practice gap between school and workplace improves learning opportunities for students.⁹ Wilson also suggests that having peers to identify with helps to bridge the theory-practice gap.⁹ Journal entries reflected “the perfect hospital” of textbooks was different from working every day and “almost being a nurse.” During the VALOR program, students immerse themselves in the realistic nursing environment of staff shortages, equipment unavailability, disgruntled patients, and peer-to-peer communication that is not always civil. The 40-hour workweek provides a realistic hands-on view of nursing and introduces students to socializing as a nurse and the nursing work culture.

After the 2013 summer portion of the program, students were able to differentiate between the realities of the world of health care and the academic view of the health care environment. As students progressed over the summer, a noticeable transformation took place. The student who wrote about needing more skills practice on day 1 found that she was comfortable with injections, hanging IVs, and providing patient care at the end of week 3. Students grew more comfortable collaborating with doctors and other interdisciplinary professionals. They also became competent with basic nursing skills and had a realistic view of the nursing world.

In addition, students became aware of the emotional aspects of nursing. One student discussed making a difference in a veteran’s life after participating in a substance abuse group. “While I was on my way home I started thinking about those vets and their stories, and I started getting emotional. I just felt bad that after doing the great deed of fighting for our country that they became victims of substance abuse,” the student explained. “That afternoon, as I departed the vets, I left hopeful and realized I could make a difference in the life of a veteran.” Another student perceived that doctors were discussing a veteran’s terminal lung cancer “nonchalantly” and reflected, “though I do recognize that a certain degree of disconnection must take place, a certain measure of empathy must remain at all times to effect positive outcomes in the patient’s health.”

VALOR students noted that the program gave them exposure to different areas of nursing. This experience assisted them in deciding on an area of nursing interest. One student who always wanted to be an emergency department nurse found that after that rotation, she was not “cut out to be an emergency department nurse.” Some students came into the program thinking they knew precisely what they wanted to do following graduation, but found a new interest.

Daily Debriefings

Through daily debriefing discussions, students learn about best practices, patient advocacy, nursing leadership, and communication skills. Some have said that it has helped them “get through the day” knowing they had an outlet to review their experiences with VALOR peers. Discussions focus on both the positive and negative aspects of their day.

Students found that group discussions bonded them as a team and allowed them to share their feelings openly. One student found, “What really impacted me was just the amount of learning I received from my VALOR friends.” The group discussions and projects allow students who may typically work in isolation to come together as a team, providing a safe outlet for reflection and self-expression. Meeting daily with peers to share personal experiences increases team cohesion. Research suggests that students learn from their peers.^10,11 Working closely with these students, the benefit of peer-to-peer learning was obvious. Students support and teach one another in a nonthreatening environment, which enhances their learning process.

End of the Summer Journey

For the students’ final journal entry, they are asked to identify their greatest fear from week 1 and describe how that has changed by week 10. Journal entries indicated that the students were no longer afraid of being a new nurse, and doctors were “not so scary anymore.” Students already know that nursing is not “going to be peachy,” but participating in the VALOR program allayed their worst fears. One student wrote, “When I had the experiences of doctors, dieticians, and physical therapists asking me questions about my patient and taking what I said seriously, it really boosted my confidence.”

Students seemed less nervous taking on the new graduate nurse role, because they practiced skills and experienced the real life of a nurse. The student who was worried about starting IVs stated, “It is second nature now.” The student who was worried about talking to doctors is now paging and communicating with them in teams. “I feel that I’m more likely to converse with other members of the health care team because of this experience,” one student reported. Another student experienced being afraid of practicing clinical skills because of her lack of experience. “I had put in only 3 IVs previously. I had never seen a cardiac catheterization,” she related.  “I had never run an electrocardiography (EKG), and I had never had an opportunity to see many of the things I have seen. I was afraid of taking a full patient load, and I was apprehensive about simple things such as hanging IV medications. I was unsure of myself, and desperately needed practice. I lacked confidence, and needed to gain experience. Now, looking back, those things seem silly.”

Coming out of this program, one student suggested, “I have found that my expectations were blown away.” The 2013 cohort walked away from the summer portion of the program with ACLS training, EKG classes, interdisciplinary team experiences, FranklinCovey personal development seminars, and most of all, hands-on experience that provided these future nurses with confidence in their abilities. Participants felt that after this summer they would be “a step ahead” of their peers when they returned to school in the fall. One student related, after returning to school, “My professor asked me to help teach an EKG class since I was ACLS certified.”

Conclusion

The goal of sharing the VALOR program and students’ experiences at the Salem VAMC is to highlight how students grow clinically and professionally. The program is not a single-person endeavor. The chief nurse executive, managers, interdisciplinary health care professionals, and nursing preceptors support the program. Gaining stakeholder buy-in for the program results in positive experiences for both students and veterans.

Taking top-performing students and grouping them as a cohort creates a learning experience for students and benefits the facility. Students develop essential nursing skills, which assist their transition to the new graduate nurse role. In the words of one student, “As this experience comes to a close, I find myself increasingly apprehensive of finishing. The VALOR position has been like a dream come true for me. I have developed as a person and a future nurse.” As the new generation of nurses, the VALORs provide the institution with fresh eyes and new ideas on how to improve the system and to care for our nation’s veterans.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

The VA Learning Opportunity Residency (VALOR) program is a prelicensure experience with a nurse preceptor for rising senior students enrolled in a bachelor of science in nursing program. Students must have a minimum 3.0 grade-point average to apply. The program provides 800 hours of paid learning experiences in diverse didactic and hands-on clinical situations. The first 400 hours of the program (10 weeks) occur over the summer, and the second 400 hours take place during the fall and spring semesters of the student’s last year of school.¹ During the last 400 hours, students are placed in the areas they are interested in working as new graduate nurses.

The aim of the Salem VALOR program is to develop the next generation of VAMC nurses by recruiting new graduate nurses. The Salem VAMC structures the VALOR program to meet the needs of both the students and the facility. According to Glenda Fuller, the student programs manager for the VA, national VALOR retention rates from 2007 to 2011 have averaged 38%. However, more applicants apply for new graduate nurse positions than are available. Included in the VHA Directive 2011-039, facilities that hire a nurse with ≤ 1 year of experience must enroll them in a yearlong transition-to-practice program.² Therefore, facilities may limit the number of new graduate nurse positions.

On entry into the VALOR program, participants write a journal entry regarding their fears and concerns about becoming a new graduate nurse. In addition, each student turns in a written reflection about their experiences each week and participates in daily group discussions with the program coordinator. The last day of the summer portion of the program, students again write about their fears and concerns about becoming a new graduate nurse. After reviewing the VALOR journals, conducting focus groups, and taking notes during the daily meetings, the authors describe the following VALOR experience from the summer of 2013 at the Salem VAMC.

Preparing New Graduates

Hospitals are under pressure to provide high-quality nursing care despite hiring new graduate nurses who are unfamiliar and inexperienced in caring for patients’ complex health care needs. New graduate nurses currently make up more than 10% of hospital nursing staff, and that number is expected to grow as baby boomers retire.³ Boswell and colleagues suggest that those new graduate nurses are unprepared for the registered nurse role.⁴ Identifying strategies to facilitate the transition from student to the new graduate nurse role will likely decrease attrition rates and increase the effectiveness and the quality of patient care. Nursing programs, such as the VALOR, can ease the transition from the classroom to the working environment.⁵

This result is evident when observing how VALOR students enhance their nursing skills after the 10-week summer program. VALOR participant Andrea King published her summer experience at the Salem VAMC in The Torch, the Virginia Nursing Students’ Association newsletter.⁶ “I had so much practice and eventually confidence in my nursing skills,” she wrote, “that I had the autonomy and independence to feel like I was working as an actual nurse.”⁶

The VALOR Experience

During the summer months, senior nursing students have the opportunity to go on rounds with the chaplain, work with nurse practitioners, attend outings with mental health patients, participate in home health visits, interact with patients in groups, and rotate to different hospital units. Students attend FranklinCovey classes (which specialize in employee performance improvement), participate in an evidence-based practice (EBP) project (which helps them to learn about teamwork), and collaborate with interdisciplinary health care professionals. At the end of the summer, students present their team EBP project to the nurse executive committee. Presentation experience assists students in acquiring public speaking skills. Students are nervous about presenting to a room full of executives. However, they learn to depend on one another and to strengthen weaknesses and build on strengths.

When high-performing students come together as one cohort, this dynamic poses challenges for the VALOR participants. One student described her vulnerability in relation to her VALOR peers as “the hardest hit to my self-confidence has been working with such intelligent and accomplished cohorts.” Another student found that even though she was at the top of her class, working with the other VALORs “challenged her self-confidence” because all the program participants were high-performing students. She found it pushed her to perform better. One person reflected, “I feel the VALOR experience has really given all of us the opportunity to unleash our full potential. I have no doubt that these students will become future health care leaders.”

Building Skills

Learning new skills and interacting with physicians are stressful experiences for new graduate nurses.⁷ A study by Casey and colleagues suggests that new graduate nurses feel inadequate and lack self-confidence.⁸ VALOR participants share these concerns. The initial journal entries revealed fears of making a mistake, harming patients, fitting in to the work culture, working with doctors, feeling anxious about patient interactions, and performing clinical skills competently.

Initially, students focused on needing extensive practice with nursing skills as evidenced by one student’s comments, “I’m honestly concerned about some of the procedures; I’ve only put in 3 IVs during nursing school, I am not confident walking in to a room and performing a procedure on my own. I would be overwhelmed.” When considering RN-to-MD communication, one student commented, “I’m nervous, doctors can be very hard on new nurses, I’ve witnessed this over and over.”

During the first weeks, the participants discussed the fear of being “on their own” without the benefit of their instructor once they graduate. One person noted this feeling as “The seed of fear grows as graduation approaches.” This lack of self-confidence and feeling scared is a consistent issue with all the VALOR students the first day of the program.

During the program, VALOR students developed nursing skills and became certified in advanced cardiac life support (ACLS). One student suggested that the ACLS class was a great team builder and instilled confidence among the VALOR participants. Another student shared, “We all agreed that attaining this certification was a culmination of our overall VA experience.” A student who was working in an acute care area applied the newly learned ACLS skills the following week when a patient coded. The student’s journal reflected how preparation makes a difference and described his experience and knowing how to react as “powerful.”

The Reality of Nursing

The VALOR program helps connect the academic environment with the realities of the workplace. Wilson found bridging the theory-practice gap between school and workplace improves learning opportunities for students.⁹ Wilson also suggests that having peers to identify with helps to bridge the theory-practice gap.⁹ Journal entries reflected “the perfect hospital” of textbooks was different from working every day and “almost being a nurse.” During the VALOR program, students immerse themselves in the realistic nursing environment of staff shortages, equipment unavailability, disgruntled patients, and peer-to-peer communication that is not always civil. The 40-hour workweek provides a realistic hands-on view of nursing and introduces students to socializing as a nurse and the nursing work culture.

After the 2013 summer portion of the program, students were able to differentiate between the realities of the world of health care and the academic view of the health care environment. As students progressed over the summer, a noticeable transformation took place. The student who wrote about needing more skills practice on day 1 found that she was comfortable with injections, hanging IVs, and providing patient care at the end of week 3. Students grew more comfortable collaborating with doctors and other interdisciplinary professionals. They also became competent with basic nursing skills and had a realistic view of the nursing world.

In addition, students became aware of the emotional aspects of nursing. One student discussed making a difference in a veteran’s life after participating in a substance abuse group. “While I was on my way home I started thinking about those vets and their stories, and I started getting emotional. I just felt bad that after doing the great deed of fighting for our country that they became victims of substance abuse,” the student explained. “That afternoon, as I departed the vets, I left hopeful and realized I could make a difference in the life of a veteran.” Another student perceived that doctors were discussing a veteran’s terminal lung cancer “nonchalantly” and reflected, “though I do recognize that a certain degree of disconnection must take place, a certain measure of empathy must remain at all times to effect positive outcomes in the patient’s health.”

VALOR students noted that the program gave them exposure to different areas of nursing. This experience assisted them in deciding on an area of nursing interest. One student who always wanted to be an emergency department nurse found that after that rotation, she was not “cut out to be an emergency department nurse.” Some students came into the program thinking they knew precisely what they wanted to do following graduation, but found a new interest.

Daily Debriefings

Through daily debriefing discussions, students learn about best practices, patient advocacy, nursing leadership, and communication skills. Some have said that it has helped them “get through the day” knowing they had an outlet to review their experiences with VALOR peers. Discussions focus on both the positive and negative aspects of their day.

Students found that group discussions bonded them as a team and allowed them to share their feelings openly. One student found, “What really impacted me was just the amount of learning I received from my VALOR friends.” The group discussions and projects allow students who may typically work in isolation to come together as a team, providing a safe outlet for reflection and self-expression. Meeting daily with peers to share personal experiences increases team cohesion. Research suggests that students learn from their peers.^10,11 Working closely with these students, the benefit of peer-to-peer learning was obvious. Students support and teach one another in a nonthreatening environment, which enhances their learning process.

End of the Summer Journey

For the students’ final journal entry, they are asked to identify their greatest fear from week 1 and describe how that has changed by week 10. Journal entries indicated that the students were no longer afraid of being a new nurse, and doctors were “not so scary anymore.” Students already know that nursing is not “going to be peachy,” but participating in the VALOR program allayed their worst fears. One student wrote, “When I had the experiences of doctors, dieticians, and physical therapists asking me questions about my patient and taking what I said seriously, it really boosted my confidence.”

Students seemed less nervous taking on the new graduate nurse role, because they practiced skills and experienced the real life of a nurse. The student who was worried about starting IVs stated, “It is second nature now.” The student who was worried about talking to doctors is now paging and communicating with them in teams. “I feel that I’m more likely to converse with other members of the health care team because of this experience,” one student reported. Another student experienced being afraid of practicing clinical skills because of her lack of experience. “I had put in only 3 IVs previously. I had never seen a cardiac catheterization,” she related.  “I had never run an electrocardiography (EKG), and I had never had an opportunity to see many of the things I have seen. I was afraid of taking a full patient load, and I was apprehensive about simple things such as hanging IV medications. I was unsure of myself, and desperately needed practice. I lacked confidence, and needed to gain experience. Now, looking back, those things seem silly.”

Coming out of this program, one student suggested, “I have found that my expectations were blown away.” The 2013 cohort walked away from the summer portion of the program with ACLS training, EKG classes, interdisciplinary team experiences, FranklinCovey personal development seminars, and most of all, hands-on experience that provided these future nurses with confidence in their abilities. Participants felt that after this summer they would be “a step ahead” of their peers when they returned to school in the fall. One student related, after returning to school, “My professor asked me to help teach an EKG class since I was ACLS certified.”

Conclusion

The goal of sharing the VALOR program and students’ experiences at the Salem VAMC is to highlight how students grow clinically and professionally. The program is not a single-person endeavor. The chief nurse executive, managers, interdisciplinary health care professionals, and nursing preceptors support the program. Gaining stakeholder buy-in for the program results in positive experiences for both students and veterans.

Taking top-performing students and grouping them as a cohort creates a learning experience for students and benefits the facility. Students develop essential nursing skills, which assist their transition to the new graduate nurse role. In the words of one student, “As this experience comes to a close, I find myself increasingly apprehensive of finishing. The VALOR position has been like a dream come true for me. I have developed as a person and a future nurse.” As the new generation of nurses, the VALORs provide the institution with fresh eyes and new ideas on how to improve the system and to care for our nation’s veterans.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.