Abstract
Background: Staff shortages, the coronavirus disease 2019 pandemic, increased patient acuity and fiscal restraints contributed to basic nursing students being assigned to intensive care units (ICU). These students, expected to step up and function within the team, were confronted with expectations and situations beyond their clinical preparation for practice. How can we better prepare these students for practice?
Objectives: To develop recommendations that promote transition programmes that prepare student nurses to become practice-ready novice general nurses to work in the ICU.
Method: The study adopted a sequential explanatory mixed-method. Quantitative data collection was achieved through census sampling and the utilisation of the Casey Fink Practice Readiness Survey. Statistical analyses used IBM SPSS (version 25, IBM Corporation) to identify predictive relationships between practice readiness and identified variables through multi-linear regression. Qualitative data collected through purposive selection and semi-structured focus group discussions were transcribed, coded and analysed through domain analysis.
Results: Four factors affecting nursing students’ perceived readiness for practice in the ICU were identified: (1) Support for new general nurses, (2) their need for professional socialisation and belonging, (3) orientation and skill development and (4) rotation and exposure to the ICU.
Conclusion: Multifaceted innovative introduction programmes may assist in preparing the novice general nurse to become practice-ready.
Contribution: This article contributes towards a possible solution to bridge the theory-practice gap and positively influence students’ transition into the workplace to facilitate retention of novice practitioners beyond their first year of practice in a specialised unit.
Keywords: practice readiness; nursing student; intensive care unit; novice general nurse; transition program; clinical learning environment.
Introduction
Nurse shortages related to the ageing nursing population, insufficient training opportunities and the inability to retain qualified nursing staff in specialised units is an international concern (Hampton, Smeltzer & Ross 2021; Hawkins, Jeong & Smith 2019; Splitgerber, Davies & Laker 2021). The magnitude of this problem was once again highlighted during the fight against the coronavirus disease 2019 (COVID-19) pandemic in 2020. The placement of final-year diploma nursing students into the intensive care units (ICU) became fundamental to attaining the required nursing capacity to provide for the sudden increase in patients with high acuity (Hampton et al. 2021; Hawkins et al. 2019; Splitgerber et al. 2021). These students were subjected to situations far beyond their basic nursing preparation (De Swardt 2019; Drennan & Ross 2019; Hawkins et al. 2019; Kaihlanen et al. 2020; Wiredu & Roberts 2020). The expectation of commencing their tasks immediately and proficiently became their reality, provoking fear, anxiety and feelings of incompetence because of their lack of experience, inability to integrate theory with practice, inadequate support structures and disregard for policy and procedure (De Swardt 2019; Drennan & Ross 2019; Hawkins, et al. 2019; Kaihlanen et al. 2020; Wiredu & Roberts 2020). The lack of orientation and professional socialisation exacerbated this situation leaving many feeling destitute and alienated.
Background within the South African context
Acquisition of the skills and values to become a practice-ready novice general nurse with the ability to take responsibility can only be obtained through experience-based knowledge. This knowledge is supported by structured facilitation and further enhanced through prolonged exposure to the clinical learning environment (CLE) (Hampton et al. 2021; Mirza et al. 2019; Murray, Sundin & Cope 2019; Rojo et al. 2020; Rush et al. 2019). South African basic nursing education programmes aim to develop the newly qualified nurse’s ability to accept responsibility and demonstrate accountability. This is achieved by encouraging self-awareness of limitations, exercising professional judgement and seeking consultation from qualified senior staff and role models (Hampton et al. 2021; Harrison et al., 2020; Innis & Calleja 2018; Rush et al. 2019).
Integration of theory into practice
Through prolonged exposure and by encouraging students to participate in real-time learning opportunities, active integration of theory and practice can be achieved (Hampton et al. 2021; Hattingh 2019; Kaihlanen et al. 2020). A prerequisite for registering as a bridging course student is being registered with the South African Nursing Council (SANC) as an enrolled nurse (R683 of 1989). This requirement ensures that all the students in this study have obtained a minimum of 2000 h of exposure to the CLE through work-integrated learning (WIL) before their registration as bridging course students (Nursing Education and Training Standards; Act 33 of 2005). During the bridging course, the student’s clinical exposure and requirements as stipulated by the SANC (Nursing Education and Training Standards; Act 33 of 2005) included an additional 2000 WIL hours to enable them to register as a general nurse (R683 of 1989). Participants were placed within accredited private healthcare facilities that could facilitate rotation through all the required disciplines to meet the requirements of the SANC. Placement of students in high care or ICU is not a requirement stipulated by the SANC (Nursing Education and Training Standards; Act 33 of 2005). However, during the COVID pandemic, acuity constraints and a severe staff shortage contributed to the placements of final-year students in high care and ICU.
Support structures
Many studies emphasise the importance of role models in the novice’s professional development (Comparcini et al. 2020; Hampton et al. 2021; Pleshkan & Hussey 2020). Moreover, peer support and the development of trust relationships assist the novices in asking for assistance from peers and seniors (Harrison et al. 2020; Menard & Maas 2019; Rush et al. 2019; Vuckovic, Karlsson & Sunnqvist 2019). The novice further needs extensive, objective support in the form of standard operating procedures, algorithms, guidelines and policy documents to guide clinical decision-making as they do not possess the required skills and critical thinking ability to act independently (Murray et al. 2019; Pitts & Christenbery 2019). In South Africa, clinical placements of students in the ICU are subject to the direct supervision of qualified staff (SA Nursing 2011). Unfortunately, the students who were placed as workforce in the ICU during the pandemic were not afforded structured and competent support from qualified senior staff. Instead, they were left to their own devices because of the severe restraints placed on the nursing fraternity.
Professional socialisation and integration as a team member
It remains a national and international expectation that all senior staff members and shift leaders should act as preceptors and role models (Smith & Sweet 2019; Watkins, Hart & Mareno 2016). Positive experiences and the effect of professional role models to guide, support and embrace students into the ICU culture are powerful and empowering (Innis & Calleja 2018; Van Den Boogaard et al. 2019). Novice nurses who experience positive interactions within the clinical environment will thrive and feel safe enough to demonstrate their actual level of competence (Comparcini et al. 2020; Harrison et al. 2020; Vuckovic et al. 2019). The novice who feels safe and supported and experiences a sense of belonging is more likely to accept responsibility and accountability for patient care (Inis & Calleja 2018; Murray et al. 2019; Rush et al. 2019).
Orientation
Orientation is one of the cornerstones to a successful transition into a new work environment (Pryse et al. 2020; Rush et al. 2019; Song & McCreary 2020). It is well documented that the transition into the ICU environment is more difficult because of the specialised knowledge and skills needed to provide quality patient care (Innis & Calleja 2018; Sterner et al. 2019; Williamson, Kane & Bunce 2020). Orientation should include unit routines, roles and responsibilities, available support structures and the development of cognitive competencies and skills required to reduce anxiety and fear of the unknown (Hampton et al. 2021; Harrison et al. 2020; Rush et al. 2019; Wiredu & Roberts 2020).
Conceptual framework
This study is underpinned by Benner’s theory of novice to expert. By adopting the Dreyfus model, Benner described five levels of skill acquisition in chronological order: (1) novice, (2) advanced beginner, (3) competent, (4) proficient and (5) expert (Alligood 2014; Landers, O’Mahony & McCarthy 2020; Murray et al. 2019; Thomas & Kellgren 2017). Benner’s theory emphasises that newly qualified nurses allocated to work in the ICU are novice practitioners based on their experience and exposure (Alligood 2014; Benner 2001; Gobet & Chassy 2008; Landers et al. 2020; Murray et al. 2019;Stinson 2017; Thomas & Kellgren 2017). The novice relies on continuous support and guidance along with clear policies and procedures to govern their behaviour (Alligood 2014; Benner 2001; Gobet & Chassy 2008; Landers et al. 2020; Murray et al. 2019; Stinson 2017; Thomas & Kellgren 2017). These novice practitioners develop skills and understanding of patient care over time through the integration of sound theoretical knowledge and practical experiences (Alligood 2014; Benner 2001; Gobet & Chassy 2008; Landers et al. 2020; Murray et al. 2019; Stinson 2017; Thomas & Kellgren 2017). Benner further emphasises that the novice will progress to an advanced beginner as clinical exposure to situational learning experiences increases (Murray et al., 2019).
Research questions and study aim
In a bid to develop recommendations regarding support structures needed to facilitate the transition from student to novice practitioner who is practice ready, it became imperative to answer the following questions: (1) What is final-year nursing students’ self-reported perception of their readiness for practice in the ICU? (2) What factors are identified by final-year nursing students that influenced their perception of readiness for practice in the ICU? (3) What is the relationship between undergraduate nursing students’ exposure to the critical care environment and the effect thereof on their perceived readiness for practice?
Research methods and design
Design and sample
This study adopted an explanatory, sequential, mixed-method approach with the collection of quantitative data, followed by a qualitative strategy aimed at verifying and explaining the quantitative results (Creswell & Creswell 2017; Gray, Grove & Sutherland 2017; Polit & Beck 2018).
Quantitative data were collected online using the Casey Fink Practice Readiness Survey (CFPRS) (Casey, Tsai & Fink 2011). All registered final-year bridging course (R683) nursing students at a private nursing education institution in South Africa were invited to participate in the study (population N = 412) through a census sampling method.
Data collection instrument
Permission to use and adapt the CFPRS for the South African context was received from its creators. The CFPRS underwent a pilot study to assess the comprehensibility of the vocabulary used, the time it took to complete the survey and the ease of understanding the instructions. The adapted CFPRS consisted of two main sections and covered the respondents’ self-reported demographic data and clinical practical experience. The demographic components were adapted to the South African context regarding qualifications, training programmes and clinical environments selected for student placement during their training. Language adaptations were made by changing ‘clinical instructor’ to’ clinical facilitator’ and ‘physician’ to ‘doctor’. Section A consisted of 21 closed structured questions and started with general demographic questions such as age and gender and progressed to more population-related specific questions. The demographic data were obtained with the application of a nominal level of measurement. Data regarding the independent variables related to the students’ clinical exposure, support and orientation in the intensive care environment during their final year of study were also assessed. Section 2 of the questionnaire directly measured the dependable variable of the respondents’ perception of their readiness for practice and enquired about respondents’ opportunities to practice skills more than once during simulation. During the data analysis, four independent variables (support structure general nurse, shifts per month overtime, attended up-skill training and orientation) were found to have significant predictive value in relation to readiness for practice scores.
Validity and reliability
The CFPRS has been validated based on construct validity, face validity, factor and confirmatory factor analysis and has been used extensively in various international studies (Baker & Alghamdi 2020; Jamieson et al. 2019). The reliability of the CFPRS instrument was already established and has a reported Cronbach’s alpha coefficient of 0.89 (Baker & Alghamdi 2020; Jamieson et al. 2019).
Semi-structured focus group discussions
The quantitative method was sequentially followed by a qualitative method and purposive sampling, through the application of two semi-structured focus group discussions consisting of four and five participants, respectively. The participants were purposively selected as they were respondents in the first phase of the study and had extensive experience of being expected to assist during the COVID-19 pandemic. Data saturation was reached during the second focus group (Gray et al. 2017; Polit & Beck 2018). The questions for the focus group discussions were derived from the results obtained during the quantitative phase. Questions asked addressed the four independent variables that influenced the student nurse’s perception of readiness for practice in a bid to gain a deeper understanding of how these factors influenced their perceived readiness for practice. These questions were: (1) Can you please explain to me or describe to me how would you describe your readiness for practice in the ICU; (2) Please can you explain or elaborate for me on what is your experience of the support received during your exposure as a student in the ICU environment; (3) What was your experience of the up-skill programme? And did you attend an up-skill programme or not; (4) How would you describe your orientation? and (5) Were there any other factors that you feel prepared you for practice readiness?
Credibility
Credibility was ensured through data triangulation, member checking, prolonged engagement and peer review (Gray et al. 2017; Polit & Beck, 2018).
Transferability
The transferability of the study’s findings was determined by the similarity of the situation in relation to the description of the purposive sampling method, a description of the participants’ demographic data, as well as the inclusion criteria for the selection of the sample population (Polit & Beck 2018).
Dependability
Dependability was ensured through a detailed description of the research design, methodology, sampling method, data collection and analysis method (Korstjens & Moser 2018).
Confirmability
Confirmability was ensured through the utilisation of a mixed-method research approach, data triangulation, member checking and the utilisation of an independent coder during qualitative data analysis (Polit & Beck 2018).
Trustworthiness
Trustworthiness was established as the researcher established credibility, dependability, transferability, authenticity and confirmability (Polit & Beck 2018).
Data collection
Data collection for this study was conducted from February 2021 to April 2022. Permission to be contacted by the researcher regarding the study was obtained by a gatekeeper. The link to the online information letter through the utilisation of Google Forms was provided to the student. Consent to be contacted was obtained from 186 students, and 109 students accessed the online survey. The response rate was 58.6%. This was followed by two semi-structured focus group discussions. The size of the focus groups was dependent on the number of participants who availed themselves of participation at the same time and logged on to attend the meeting on the day of the discussion. Four and five participants attended the focus groups, respectively. Data saturation was reached during the second focus group as no new data emerged (Gray et al. 2017; Polit & Beck 2018).
Data analyses
Data collected during the quantitative phase were captured using an online platform (Google Forms) and exported into an Excel spreadsheet. The data were cleaned and coded numerically (Boswell & Cannon 2020; Gray et al. 2017). IBM (SPSS) (version 27, IBM Corporation, New York, US) was used to analyse the data. Demographic and response variables were described by frequency analysis and calculation of means, 95% confidence intervals or medians and interquartile ranges. Differences in mean scores between groups assigned to specialised and peripheral hospitals during training were assessed using a t-test. Predictive relationships between readiness for practice scores, orientation, clinical exposure to the intensive care environment, support in the ICU and attendance of a skill development programme were assessed using multivariate linear regression.
During qualitative data analysis, domain analysis was performed by the researcher, supervisor and an independent coder. The verbatim transcriptions of the audio recordings of the focus group discussions were coded in the following manner: (1) Identification of primary domains, (2) constructing a taxonomy of sub-domains, (3) specifying the components and (4) the domains were related to each other. Meetings were conducted between the researcher, supervisor and independent coder to review and refine the identified domains and sub-domains. The final agreed-on themes, domains and sub-domains are summarised in Table 7. The integrated quantitative and qualitative results identified four factors that affected the nursing students’ perceived readiness for practice in the ICU environment: (1) Support for new graduates, (2) their need for professional socialisation and belonging, (3) orientation and skill development and (4) rotation and exposure in the clinical learning environment as a student. The results were supported by literature for integration purposes (Gray et al. 2017).
Ethical considerations
Ethical clearance to conduct this study was obtained from the University of Johannesburg Faculty of Health Sciences Research Ethics Committee (reference no.: REC-512-2020). Ethical approval was granted by the University of Johannesburg, the Private Nursing Education Institution and the affiliated Private Health Care Provider. Students consented to be contacted with regard to the study. Informed consent was obtained from the respondents for the quantitative as well as the qualitative phase of the study. Participation was thus voluntary, and confidentiality during the quantitative phase of the study was assured. Participants were made aware that complete confidentiality could not be assured during the qualitative phase of the study as the participants might know each other. However, the participants, the independent coder, as well as the moderator were asked to sign a confidentiality clause (Polit & Beck 2018). Consent to digital record the focus group sessions was also obtained.
Results
Quantitative results
As indicated in Table 1 only 88 responses could be utilised during quantitative data collection as not all the questionnaires were completed in full.
| TABLE 1: Demographic and work characteristics. |
Demographic data
Age and gender
The age distribution of respondents for this study ranged from 25 years to 53 years ([Mean] M = 32; standard deviation [s.d.] 7.032). The mean age of the target population was 33 years. Most respondents (63.6%; n = 58) were between the ages of 25 and 34. This age distribution is representative of the target population, with an average of 61% in the same age group (National Statistical Report of Private Education Institution 2021). Female respondents in this study accounted for 90.9% (n = 80) of the respondents, and 9.1% (n = 8) were male. The gender distribution for this study is representative of the target population, with 92.2% (n = 380) females and 7.8% (n = 32) males.
Prior qualifications and related experience
Prior qualifications before enrolment as a bridging course student vary because of the nature of opportunities available to progress. Experience gained as well as the last unit of employment prior to enrolment to the bridging course as stipulated in Regulation 683 (R683) of the Nursing Act (No. 33 of 2005) varies because of personal circumstances and progression opportunities related to each individual student (Hampton et al. 2021:4). The geographic distribution of the respondents is representative of all five campuses nationally and in line with the size of the private education institution (PEI) in each province (National Statistical Report of Private Education Institution 2021.
Exposure to the intensive care unit clinical learning environment as a final-year nursing student
Work-integrated learning during the final year of studies varied based on the previous year’s clinical placements and planned rotation within available space in the CLE according to the requirements as stipulated by the SANC (Nursing Education and Training Standards; Act 33 of 2005:4). As indicated in Table 2, most respondents work voluntary overtime shifts in ICU and was compensated for these shifts. Respondents who worked more than four shifts per month accounted for 24% (n = 21). Respondents working four overtime shifts per month represented 10% (n = 9) of the sample, while 15% (n = 13) worked two overtime shifts. Respondents who worked three overtime shifts represented 5% (n = 4) of the sample, and the remaining 4% (n = 4) worked one overtime shift. The remaining 42.0% (n = 37) respondents did not work any voluntary overtime shifts in the ICU.
| TABLE 2: Prolonged exposure to the clinical learning environment. |
Orientation received as students allocated to the intensive care unit
As indicated in Table 3, 64.8% (n = 57) of respondents were orientated to the ICU environment, while 35.2% (n = 31) were not orientated. Most respondents (40.4%; n = 23) rated the quality of orientation as average, followed by 29.8% (n = 17) rating orientation quality as good.
| TABLE 3: Orientation received during allocation to the intensive care unit clinical learning environment as a student. |
Support structures available to the students
As illustrated in Table 4, most respondents felt they were not supported by the CNS. They indicated that they were moderately supported by the unit manager, CF and other general nurses. The respondents indicated they were fully supported by the shift leader and their peers.
| TABLE 4: Support structures available during allocation as a student to the intensive care unit clinical learning environment. |
Opportunity to practice procedures during simulation
As indicated in Table 5, 78 of the respondents (92%) stated that they had the opportunity to practice skills in simulation during their basic training, and 67 respondents (77%) indicated they did not feel competent to perform these skills in the clinical environment yet. Respondents who indicated they felt simulation contributed to their readiness for practice accounted for 44% of the population.
| TABLE 5: Opportunity to practice during simulation during up-skill training sessions and self-perceived readiness for practice as a novice in the intensive care unit. |
Self-perceived readiness for practice
During an independent sample t-test, differences between mean readiness for practice scores for respondents allocated to peripheral (n = 16) versus specialist (n = 39) hospitals were compared as indicated in Table 6. The results illustrated that there was no significant difference between the two groups (mean difference = −0.270, 95% confidence interval for difference = −0.940; 0.401, t = −0.811, p = 0.422) with equal variances assumed (Levene’s test, p = 0.629).
| TABLE 6: Mean readiness scores for respondents in different provinces allocated to peripheral and specialised hospitals for clinical experience. |
Two separate one-way ANOVA tests were conducted, comparing mean readiness scores across different provinces for respondents allocated to peripheral (n = 16) and specialised (n = 39) hospitals. There were no significant differences identified in different provinces on readiness for practice scores among respondents allocated to peripheral or specialised units (peripheral group: F = 3.174, p = 0.064; specialised group: F = 0.713, p = 0.551). These results are further supported by the results of the independent sample t-test, where the null hypothesis could not be ruled out.
Qualitative results
During the qualitative data analysis, three domains and seven sub-domains were identified. The described domains and sub-domains are directly supported by participants’ quotes, as indicated in italics in Table 7.
| TABLE 7: Summary of the domains and sub-domains related to the participants’ lived experiences that impacted their self-perceived readiness for practice in the intensive care unit. |
Discussion
Prolonged exposure to the intensive care unit clinical learning environment
Prolonged exposure to the ICU environment influenced the student nurse’s perceived readiness for practice as they were exposed to situational learning opportunities (Pryse et al. 2020; Rush et al. 2019). Voluntary compensated overtime shifts resulted in prolonged exposure to the ICU environment. Students allocated to specialised hospitals were more likely to be exposed to the ICU environment because of rotational placement and the opportunity to work overtime. The results indicated no significant difference in practice readiness scores between students allocated to peripheral and specialised hospitals. These results were surprising. Based on Benner’s theory, novice nurses are expected to develop skills and understanding of patient care over time. Benner’s theory further suggests that knowledge and decision-making skills are gained in specific situations in relation to exposure to the CLE. As a result, it was expected that students who worked more overtime shifts in the ICU and were placed in a specialised hospital would report a higher readiness for practice score.
These results could be explained by the prerequisite requirements that all the respondents had 3 years of experience and clinical exposure in a general ward and met the outcomes stipulated in the curriculum, as described by the Nursing Act (No. 33 of 2005) prior to their enrolment as a bridging course student. Based on the practice readiness scores and in accordance with Benner’s classification of development, with consideration of prior exposure to the ICU, the newly qualified nurses in this study were classified as novices or, at the most, advanced beginners (Alligood 2014; Benner 2001; Landers et al. 2020; Murray et al. 2019; Thomas & Kellgren 2017).
Support professional socialisation and belonging
Benner (2001) identifies the need for guidance from preceptors and experts for the novice and advanced beginner as a lifeline in a new and unfamiliar situation. As indicated in Table 7 and confirmed through data triangulation as indicated under Domain 2 and illustrated in Sub-domain 2.1., respondents were mainly supported by the shift leader and their peers. Because of the guidance, supervision and support offered by the shift leader, the students were able to build a trusting relationship that made them feel safe and accepted as valuable members of the team (Murray et al. 2019; Nyiringango et al. 2021). If the shift leader embraced the opportunity to allow the students to benefit from valuable situational learning opportunities, they would deliberately involve the students in these learning moments (Harrison et al. 2020; Wiredu & Roberts 2020). Positive mentors are irreplaceable in facilitating the novice’s transition into a new working environment and promoting professional growth and independence (Comparcini et al. 2020; Nyiringango et al. 2021; Wong & Bressington 2021). The students clearly indicated that the ENA was especially valuable with regard to orientation to the layout, stock placement and routine of the unit as indicated in Domain 2 (Sub-domain 2.1). This was a surprising result as the ENA is considered a junior staff member and the importance of their role in the team dynamics is often overlooked.
Orientation and skill development
As explained by Benner’s theory, the novice relies on standardised policies and procedures, as well as a set routine, to provide them with structure and a sense of security that they are doing what is expected of them (Pryse et al. 2020; Rush et al. 2019;Song & McCreary 2020). Receiving orientation on the routine in the unit will assist them with prioritising tasks (Alligood 2014; Benner 2001; Landers et al. 2020; Murray et al. 2019; Thomas & Kellgren 2017). Orientation underpins the understanding of what is expected of them as members of the multi-disciplinary team (Rodríguez-García et al. 2018). In the absence of proper orientation, the newly employed nurse will feel overwhelmed, frustrated and incompetent (Pleshkan & Hussey 2020). As per Table 8, the results indicated that the students did not view orientation as one of the three most important factors that influenced their self-perceived readiness for practice in the ICU. However, during the qualitative phase of the study, the participants explained the importance of orientation and how not being orientated affect their ability to function independently as valuable members of the team. The quantitative results could be explained as students were exposed to the ICU during their studies prior to enrolment as bridging course students. Based on prior exposure, they did not feel completely lost or disorientated and were familiar with some of the policies, procedures and routines related to the ICU CLE. Through triangulation of the results, the importance of systematic orientation cannot be ignored as a contributing factor to the nurse’s perceived readiness for practice.
| TABLE 8: Indicators for readiness for practice. |
Skill development through simulation
As indicated in Table 7, students indicated that even though they were given the opportunity to practice some skills in simulation during their basic training, they did not feel competent to perform these skills in the clinical environment. As indicated in Domain 3, Sub-domain 3.1, participants indicated that if they had the opportunity to attend an up-skill programme, they would have been better prepared for practice. Through an up-skill programme, students could have had the opportunity to integrate theory and practice (Jørgensen, Larsen & Gram 2018; Menard & Maas 2019; Tjoflåt, Koyo & Bø 2021). They acknowledged the need to practice the required new skills in a safe environment before being expected to do so in reality (Jørgensen et al. 2018; Menard & Maas 2019; Tjoflåt et al. 2021).
Recommendations
Multifaceted, innovative introduction programmes may help close the gap, assisting the student to become a novice general nurse who is practice ready. Nurse managers must support and encourage a culture of caring for students, lifelong learning and provision of learning support to students allocated to their units during WIL (Comparcini et al. 2020; Hattingh 2019). This positive culture towards students will foster evidence-based practices and enhance patient safety (Comparcini et al. 2020; Hampton et al. 2021; Harrison et al. 2020). Through the revision and implementation of standardised policies and procedures, the necessary objective guidance and support are provided to students to facilitate the provision of evidence-based safe patient care (Murray et al. 2019; Pitts & Christenbery 2019).
Formally planned, structured unit-specific orientation programmes should be introduced prior to students being allocated to the unit for WIL opportunities (Hampton et al. 2021; Hattingh 2019; Innis & Calleja 2018; Pleshkan & Hussey 2020). Orientation programmes should include an introduction to the unit manager and co-workers, unit routines and teamwork, communication structures, as well as clear expectations regarding team assistance and equipment operation (Hampton et al. 2021; Harrison et al. 2020; Hattingh 2019; Rush et al. 2019; Wiredu & Roberts 2020). Orientation of students should be allocated to a dedicated staff member (Comparcini et al. 2020; Gómez-Ibáñez et al. 2020; Vuckovic et al. 2019).
The appointment of a CNS with a clearly defined role description related to student allocation, facilitation, support, orientation, staff development and training in collaboration with the clinical facilitator will contribute to a positive culture that promotes lifelong learning (Comparcini et al. 2020; Hattingh 2019). Additionally, the implementation of a mentor system, where students can engage in professional socialisation that promotes personal and professional growth, will promote a feeling of belonging (Comparcini et al. 2020; Hampton et al. 2021; Pleshkan & Hussey 2020). To enhance peer support, the allocation of at least two students to the same ICU on the same shift is recommended (Price et al. 2018; Rush et al. 2019; Vuckovic et al. 2019).
All final-year students should be afforded the opportunity to attend an upskilling programme prior to the commencement of allocation to an ICU. Such programmes will ensure competence in performing the basic skills required to participate as a functional member of the team (Deschênes et al. 2019; Lee, Kim & Chae 2020; Sterner et al. 2019). Skills should be practised in a simulation until competence is demonstrated and reinforced during WIL under the direct supervision of the clinical nurse specialist (CNS), shift leader (SL) and mentor (Deschênes et al. 2019; Lee et al. 2020; Sterner et al. 2019).
The PEI should continuously monitor and improve implemented transition programmes through trial and error. These transition programmes should be shared, standardised and implemented on a national level within the PEI and their affiliated healthcare providers to promote the accessibility of a well-developed transition programme to all students (Hattingh 2019).
Strengths and limitations
The study’s results are limited to students registered for the bridging course (R683) and should not be generalised. The sample population for the t-test based on the study’s hypothesis consisted of only 44 respondents. Most respondents (34) were allocated to specialised hospitals, and it is thus possible that the results could be biased. This study was sequential and explanatory and employed a mixed-method approach. The results obtained during the first phase were confirmed and elaborated on during the study’s second phase. It appears to be the first study in South Africa that explored the possibility of placing newly qualified general nurses in the ICU setting. Valuable insights were gained from this mixed-method approach, and the recommendations were aimed at developing support programmes. These support programmes could bridge the gap between being a student and becoming a novice general nurse who could transition into the ICU. These recommendations could promote a smooth transition into practice for all categories of future nursing students and newly employed staff in the ICU. By implementing the recommendations, staff retention in the ICU and burnout could be positively influenced.
Conclusion
The preparation-practice gap is a reality and a threat to quality patient care (Innis & Calleja 2018). To enable the novice to provide quality patient care in the intensive care setting, adequate objective and subjective support that contributes to the novice’s sense of security needs to be prioritised (Comparcini et al. 2020; Hampton et al. 2021; Harrison et al. 2020). The development of professional competence and the ability to take responsibility can only be obtained through experience-based knowledge supported by continuous professional development programmes (Hampton et al. 2021; Innes & Calleja 2018; Splitgerber et al. 2021). The quality of patient care can be improved by the development and implementation of transitional programmes aimed at developing the novice’s ability to accept responsibility and demonstrate accountability, by self-recognition of their limitations, exercising professional judgement and seeking consultation with their seniors and role models (Cheraghi et al. 2021; Gómez-Ibáñez et al. 2020; Innes & Calleja 2018; Murray et al. 2019). As each learning environment is unique and context specific, it is important to identify the factors that are predictive of readiness for each situation (Casey et al. 2021). Only once these factors are identified and understood within the context can transition programmes be developed to promote practice readiness (Casey et al. 2021).
Acknowledgements
The authors thank all the participants for sharing their most personal and valued experiences. This article is partially based on the author’s dissertation entitled ‘Practice readiness of final-year nursing students in intensive care in a private hospital group’ towards the degree of Master of Nursing Science in Ethos and Professional Practice in the Department of Nursing, Faculty of Health Science, University of Johannesburg, Johannesburg, South Africa in October 2022, with supervisor, Prof., Charlene Downing.
Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Authors’ contributions
L.O. and C.D. conceptualised the study, conducted the data analysis and wrote and revised the manuscript for important intellectual content. L.O. was responsible for the data collection for the research.
Funding information
The research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data availability
The authors confirm that the data supporting the findings of this study are available within the article.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.
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