Linda Lea, MBA, Pa-C

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

Nursing students who participated in the VALOR externship felt confident in their clinical skills when they were transitioning to the RN role.

Author(s)

Debra Shipman, PhD, RN

Jack Hooten, MHA, MSN, RN

Linda Lea, MBA, Pa-C

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

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

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

Literature Review

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

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

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

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

Methods

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

Interviewees

Nurses in the VALOR externship in 2011 and 2012 were contacted. Study inclusion criteria were participation in the summer portion of VALOR, current full-time or part-time RN employment, and licensed nursing experience of at least 3 months but not more than 2 years. Researchers suggest that a new graduate nurse has less than 2 years’ experience.²⁵Interviewees were from California, Florida, North Carolina, Virginia, and West Virginia. Employment at a VAMC was not a study requirement (Table).

Data Collection and Analysis

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

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

Results

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

Confidence

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

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

Transitioning to RN Role

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

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

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

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

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

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

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

Decision Making

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

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

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

Interacting With Professionals

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

Discussion

The present study found that nursing students who had been in the VALOR externship felt confident in their clinical skills when they were transitioning to the RN role. Other studies similarly have found that externship students were self-confident assuming the RN role, owing to their additional clinical experience.^12,28The 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.

Limitations

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

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

Future Research

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

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

Conclusion

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

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

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

References

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Author and Disclosure Information

Dr. Shipman and Mr. Hooten are nurse educators, and Ms. Lea is a physician assistant, all at the Salem VAMC in Virginia. Mr. Hooten is adjunct faculty at Jefferson College of Health Sciences in Roanoke, Virginia.

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.

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Federal Practitioner - 33(7)

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29-33

Legacy Keywords

registered nurse, Veterans Affairs Learning Opportunity Residency, education

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