Program Profile

The Unique Value of Externships to Nursing Education and Health Care Organizations

Fed Pract. 2016 July;33(7):29-33

References

1. Clark CM, Springer PJ. Nurse residents' first-hand accounts on transition to practice. Nurs Outlook. 2012;60(4):e2-e8.

2. Myers S, Reidy P, French B, McHale J, Chisholm M, Griffin M. Safety concerns of hospital-based new-to-practice registered nurses and their preceptors. J Contin Educ Nurs. 2010;41(4):163-171.

3. Nuttall CM. A Comparative Study Evaluating the Impact of Participation in a VALOR Nurse Externship on Job Satisfaction, Sense of Belonging, Role Socialization and Sense of Professionalism: Transition From Graduate to Registered Nurse [dissertation]. Albuquerque: University of New Mexico; 2010.

4. Steen JE, Gould EW, Raingruber B, Hill J. Effect of student nurse intern position on ease of transition from student nurse to registered nurse. J Nurs Staff Dev. 2011;27(4):181-186.

5. Ulrich B, Krozek C, Early S, Ashlock CH, Africa LM, Carman ML. Improving retention, confidence, and competence of new graduate nurses: results from a 10-year longitudinal database. Nurs Econ. 2010;28(6):363-375.

6. Casey K, Fink R, Jaynes C, Campbell L, Cook P, Wilson V. Readiness for practice: the senior practicum experience. J Nurs Educ. 2011;50(11):646-652.

7. Shipman D, Hooten J, Stanley S. The VALOR program: preparing nursing students to care for our veterans. Fed Pract. 2014;31(9):35-38.

8. Walker A, Earl C, Costa B, Cuddihy L. Graduate nurses' transition and integration into the workplace: a qualitative comparison of graduate nurses' and nurse unit managers' perspectives. Nurs Educ Today. 2013;33(3):291-296.

9. Welding NM. Creating a nursing residency: decrease turnover and increase clinical competence. Medsurg Nurs. 2011;20(1):37-40.

10. Morrow S. New graduate transitions: leaving the nest, joining the flight. J Nurs Manag. 2009;17(3):278-287.

11. Parker V, Giles M, Lantry G, McMillan M. New graduate nurses' experience in their first year of practice. Nurs Educ Today. 2014;34(1):150-156.

12. Ruth-Sahd LA, Beck J, McCall C. Transformative learning during a nursing externship program: the reflections of senior nursing students. Nurs Educ Perspect. 2010;31(2):78-83.

13. White AH. Clinical decision making among fourth-year nursing students: an interpretive study. J Nurs Educ. 2003;42(3):113-121.

14. Kropkowski LR, Most R. Set for success: nurse "externs." Nurs Manag. 2008;39(7):8-9.

15. Rhoads J, Sensenig K, Ruth-Sahd L, Thompson E. Nursing externship: a collaborative endeavor between nursing education and nursing administration. Dimens Crit Care Nurs. 2003;22(6):255-258.

16. Hillman L, Foster RR. The impact of a nursing transitions programme on retention and cost savings. J Nurs Manag. 2011;19(1):50-56.

17. Baernholdt M, Mark BA. The nurse work environment, job satisfaction and turnover rates in rural and urban nursing units. J Nurs Manag. 2009;17(8):994-1001.

18. Jones CB. Revisiting nurse turnover costs: adjusting for inflation. J Nurs Adm. 2008;38(1):11-18.

19. Pine R, Tart K. Return on investment: benefits and challenges of baccalaureate nurse residency program. Nurs Econ. 2007;25(1):13-18, 39.

20. Beecroft PC, Dorey F, Wenten M. Turnover intention in new graduate nurses: a multivariate analysis. J Adv Nurs, 2008;62(1):41-52.

21. Phillips C, Esterman A, Kenny A. The theory of organisational socialisation and its potential for improving transition experiences for new graduate nurses. Nurs Educ Today. 2015;35(1):118-124.

22. Diefenbeck CA, Plowfield LA, Herrman JW. Clinical immersion: a residency model for nursing education. Nurs Educ Perspect. 2006;27(2):72-79.

23. Cantrell MA, Browne AM. The impact of a nurse externship on the transition process from graduate to registered nurse: part III. Recruitment and retention effects. J Nurs Staff Dev. 2006;22(1):11-14.

24. Kilpatrick K, Frunchak V. The nursing extern program: innovative strategies for students in transition. Health Care Manag (Frederick). 2006;25(3):236-242.

25. Kovner CT, Brewer CS, Fairchild S, Poornima S, Kim H, Djukic CM. Newly licensed RN's characteristics, work attitudes, and intentions to work. Am J Nurs. 2007;107(9):58-70

26. van Manen M. Researching Lived Experience: Human Science for an Action Sensitive Pedagogy. Albany: State University of New York Press; 1990.

27. Lincoln YS, Guba EG. Naturalistic Inquiry. Beverly Hills, CA: Sage; 1985.

28. Starr K, Conley VM. Becoming a registered nurse: the nurse extern experience. J Contin Educ Nurs. 2006;37(2):86-92.

29. Hasson F, McKenna HP, Keeney S. Delegating and supervising unregistered professionals: the student nurse experience. Nurs Educ Today. 2013;33(3):229-235.

30. Kramer M, Maguire P, Halfer D, et al. The organizational transformative power of nurse residency programs. Nurs Adm Q. 2012;36(2):155-168.

31. Rush KL, Peel K, McCracken B. Empowered learning on the inside: an externship experience. Nurs Educ Perspect. 2004;25(6):284-291

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.^12,28The 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.