During my senior year of nursing school, I tried to do everything right to prepare for my first nursing job. I thought I understood the system. I was wrong.

I didn’t understand many aspects of beginning a job in a hospital: the hospital residency, the orientation requirements, and the limits on clinical areas where new grads could work. Plus, these varied widely from hospital to hospital, complicating the weighing of the pros and cons of one job against another.

I was surprised to learn that in some hospitals I’d have to “pay back” the time the hospital invested in training me. Depending on the residency and the hospital, I might have to commit to working as long as 2½ years in the same position. What if I made a commitment and then found out that I hated that type of work? Or I hated the schedule? What if I decided I wanted to change focus completely and work as a public health nurse?

Another hurdle in my career path was the lack of enthusiasm hospital administrators have for hiring new nurses who are continuing their education. This seems inconsistent with the need for ongoing learning and career development. Some of us were advised to not mention this during our interviews, but that would be dishonest. These days, nursing programs are filled with older, second-degree students who bring other life experiences to the profession. Why restrict them from moving quickly by continuing their education if they discover where they want to go?

For now, I’ve decided to go to graduate school and find a part-time job that suits my schedule. But this decision doesn’t address the challenges I discovered when trying to find my first full-time nursing position.
—Rebecca Wheeler, RN

An expert response
A couple of terms seem to be causing confusion. Let me try to clarify them.

Most healthcare facilities provide new graduate orientation programs. These programs focus on the new graduate’s needs and can last from 6 weeks to 6 months, depending on the facility and unit.

Orientation programs combine classroom instruction (usually facilitated by the Nursing Education department) with clinical orientation that pairs the new grad with a unit preceptor. Generally, the new graduate is expected to spend at least one year on the nursing unit where she or he has accepted a position.

Making a change before that simply isn’t prudent in most cases. Most new graduates need 9 to 12 months before they start feeling comfortable in their positions. Sometimes, despite everyone’s best efforts during the interview process, the unit and the new grad don’t seem to be a good fit. If interventions by the hiring manager and educator don’t help, a unit change may be best for the new grad and the healthcare facility.

Nurse externship programs are offered to nursing students who have completed their junior year in a baccalaureate program or one year of clinical in an associate or diploma program. The goal is to provide more clinical experience.

A residency, which isn’t offered by all healthcare facilities, is separate from the new graduate orientation program. The residency is offered to a limited number of new graduates for a specified number of weeks. The new graduate rotates through nursing units and at the end of the program applies for a position on one of them. The goal of the program is to allow the new graduate to make an informed decision regarding a position. The commitment for this program is 2 years.

— Patricia A. Brady, MAS, RN, CHCR, President of the NJ Association for Healthcare RecruitersA second opinion

New graduate orientation programs have many names and formats. Common names include mentorship, internship, residency, and new graduate transition. Most programs provide a general orientation to the organization, its mission, vision, values, and policies, plus the nuts and bolts of employment. New graduate programs include classroom time and clinical time aimed at helping the graduate gain the required competence for a chosen area.

The fact that the word residency is used in different ways in different programs may cause some confusion. One program sponsored by the University Health System Consortium (UHC) and the American Association of Colleges of Nursing (AACN) is the Postbaccalaureate Nurse Residency Program. This 1-year program is designed to facilitate the transition of new BSN and higher-degree graduates to competent acute-care nurses in academic medical centers.

No matter what a program is called, during your job search, gather as much information as possible, including the duration, areas available, and the amount of classroom and clinical time. And be sure to find out if the program involves a service commitment—what Rebecca called pay back. Before you accept a position, be sure you understand the program.

Remember, you’re not just accepting a job. You’re beginning your professional development. Keep in mind that hiring and orienting a new nurse is expensive. Many organizations spend the equivalent of 1-year’s salary in the process. That’s why many include a service commitment as part of a special structured program for new graduates. Others may use this strategy when sign-on bonuses are provided. Employers want to keep their new hires—not only because of their investment but also to maintain continuity of care.

Organizations hiring new graduates need to provide a nurturing environment. But because some areas require such complex skills, they are not available to new graduates. Depending on the hospital, a highly specialized area that requires a great deal of solo decision-making or one that requires sophisticated, experience-based skills may not allow new graduates. Other settings may not have enough experienced nurses to act as preceptors and thus may not be good places for initial learning and competency development.

What happens if you encounter problems during your commitment period? First, try to resolve them with your preceptor or manager. If one of them is the problem, give other nursing leaders a chance to help you. Don’t suffer in silence.

— Pamela F. Cipriano, PhD, RN, FAAN,
Chief Clinical Officer and Chief Nursing Officer,
University of Virginia Health System, Charlottesville, Va.