Originally Published in Nursing Leadership, 17(1) : 1–4 March 2004

I recently sat beside a nice young man on a flight from Ottawa to Toronto. As we chatted, he told me he was a lawyer who had practised for five years in a big Bay Street firm but left it because he hated it. He loved the law and he loved studying it, but he found the practice of law – at least the way it is practised in big firms – to be soul-destroying. He sought advice from another lawyer who has never actually practised law but has done just about everything else and done it brilliantly. The older lawyer's advice was: "Get out and do what you enjoy. Your knowledge of the law will serve you well." This young man got out and is using his skills in the political/governmental arena. He's not making as much money but he's excited about what he is doing – working hard but enjoying it. Does this sound familiar? Substitute nursing for the law and nurse for lawyer, and most of us have heard similar stories. There's one big difference, though: We're not short of lawyers. We are short of nurses. He asked me about nursing. He had heard it was in trouble and wanted to know what that was about. I discovered that the 45 minutes from Ottawa to Toronto is not nearly long enough to explain nursing's current woes. I could have used the distance to Vancouver or maybe even Australia!

Among the many difficult circumstances confronting us is the problem new graduates in clinical situations face in the absence of experienced colleagues to guide them. I have come to know a very able young nurse who graduated with her BScN last spring. She works in one of the most specialized and demanding areas of a teaching hospital, caring for patients who are very ill and whose conditions are highly volatile. The unit is heavily staffed with new graduates – 75% have less than one year of experience and no one has more than five years, which means that on many shifts the new graduates are the only ones working. They always work "short," so each of these young nurses is caring for four to six patients instead of the two to three patients the staffing plan recommends. They all work at the outer limits of their competency. They have not had enough experience to develop the expertise to recognize many of the early signs that a patient is getting into trouble.

On many shifts (picture those 12-hour night shifts), they do not have anyone readily available to answer questions or to come and look at their patient to be sure the new graduate is not missing something.

This young nurse will not stay where she is. She says there is too much risk of something going wrong and that is not the way she wants to manage her career or to practice. Her young colleagues feel the same way. Every time they finish a shift, they are grateful to have survived and that their patients survived them.

Does she like the work? Absolutely. She loves the patient care and all that she is learning. Yet, after a year, like many other young graduates, she will be gone, maybe into another area of nursing or maybe out of nursing using that excellent preparation to forge a career in another field. The future demographics in nursing point to increasing proportions of new graduates and nurses with only one to two years of experience staffing all parts of the healthcare system as the experienced cohort retires.

I have been an advocate of baccalaureate education for nurses my entire career. However, it comes with a risk. Disillusioned degree-prepared nurses can more easily move into other professions than can diploma-prepared nurses. Most professional schools now require a baccalaureate degree for admission: teaching, social work, physical and occupational therapy, law, medicine, dentistry – and several of them require only one or two years of study. Nurses can move into those fields and work at nursing part-time as they prepare themselves to move out of it as a career. Nursing has to be a very good career in order to hold on to them against competition from other careers.

I have wondered what kind of research we might do to assist us through what will be a long and challenging period. Here are just a few questions to which we need answers.

1. What models of 24-hour expertise can be made available to inexperienced nurses who are staffing high-risk areas (or frankly any area) without benefit of experienced colleagues? What type of assistance do novice nurses seek? What outcomes are relevant in determining the effectiveness of various support models?
2. What role can IT play in this?
3. What role do best-practice guidelines play in supporting inexperienced nurses? Do they result in nurses feeling more secure, in improved patient outcomes and in fewer adverse events? Is there a difference in effect when nurses have little as compared to a lot of experience? Do best-practice guidelines function more or less effectively in the absence of other types of supports such as experienced colleagues?
4. Is it possible to accelerate the acquisition of judgement, in other words, to accelerate the process of moving from novice to expert as described by Benner? What are the mechanisms, and do they vary depending on the type of expertise required?
5. Is the configuration of nursing education optimal for achieving confidence, assessment and judgement in new graduates in today's healthcare environment?

Nursing now – and for the foreseeable future – will be greatly challenged by its demographics. Increasing the number of new graduates will not achieve the goal of replenishing the supply of nurses if we are unable to retain these young graduates in the workforce because there are too few supports for them to grow into the kind of nurses they entered the profession to become. Research should help us manage this situation.

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