Piedmont Hospital charge nurse Cindy Ottinger, left, watches Georgia Baptist College nursing student Christa Sutton as she listens to Leroy Osborne's heart. Sutton is gaining experience in Piedmont's externship program.

Call it the cocoon syndrome. In nursing school, everything is neatly packaged and structured. Instructors are nurturing, fellow nursing students are supportive and it seems like you're part of one big happy family.

Then you graduate, get a job and reality hits. "These nurses come from this nurturing environment. Then they go out, and patients are mean to you or family members yell at you. It's a shock to them," said Jo Ellen Hooker, RN, director of nursing resources at Piedmont Hospital.

Hooker sees a good deal of the "deer-in-theheadlights" panic of nursing school graduates who realize that the routine schedules of the academic world don't reflect daily nursing.

In her job, Hooker visits career fairs and interviews hundreds of nursing students and nursing graduates. She also oversees the hospital's summer externship and scholarship programs, and its nursing re-entry program.

Her advice: Get experience before you hit the door. Make sure you know what's expected of you before you sign a contract. And, once you have a job, continue to advance your professional knowledge.

"Nursing school doesn't fully prepare you for the extraneous things that happen in a day," Hooker said. "A lot of grads that I interview say that they just don't feel prepared for the reality of nursing. Just being able to juggle your day - be in by 6:45 a.m. and out by 7:15 p.m. - is an art; it's learned skill."

Sometimes that skill is never learned. Nursing schools have become acutely aware of high turnover rates of new graduates, many of whom leave nursing within a year.

"We have done focus groups with the deans of BSN programs with practice partners, and what we've found is students [who leave] are unhappy in the environments they went to work in," said Anne Rhome, RN, MPH, deputy director of the American Association of Colleges of Nursing.

"They didn't feel like they were being allowed to do what they were taught to do in their program, and weren't intellectually or professionally fulfilled. Some also felt like it was not a safe working environment because of staffing."

"Nursing school doesn't fully prepare you for the extraneous things that happen in a day. A lot of grads that I interview say that they just don't feel prepared for the reality of nursing."

- Jo Ellen Hooker
Director of Nursing Resources at Piedmont Hospital

A steep learning curve
Being unprepared to multitask and prioritize in the fast-paced world of hospital nursing is another problem. In February, Hooker served on a Georgia League of Nurses panel with other nursing administrators and nursing school deans to explore new graduate competencies.

"Teaching critical thinking skills is paramount," Hooker said. "In the past, these were skills you learned on the job; but we're finding - because of the acuity of patients today and the number of patients these new graduates need to care for - they have to develop critical thinking skills prior to the transition from student to nurse."

Nursing students may need to look seriously at schools that utilize simulated anatomically correct models and computerized modules that mimic real nursing situations, she said.

"These modules are something that is definitely a trend in the future, and it's important that nursing schools have these types of laboratories available," Hooker said.

Currently, Emory University, Georgia Baptist College at Mercer, Georgia State University, Kennesaw State University, Georgia Perimeter College and the Medical College of Georgia have the simulated model programs.

While the lab experience is important in developing critical care skills, students should also seek reallife experience by applying for externships during their college years, Hooker and Rhome said.

Piedmont is just one hospital in metro Atlanta that offers a nine-week salaried extern program for rising senior nursing students. Piedmont's program requires students to work three 12-hour shifts a week with one nurse preceptor.

"They do everything the [experienced] nurse does, except administer medication," Hooker said. She hired 44 externs for this summer's program. An externship "helps you transition into your senior year and helps you pull together your organizational skills," Hooker added.

Pilot residency program
While externships augment a nursing student's clinical requirements for graduation, they are not required. However, that could change.

A residency program is being piloted in 12 university-based hospitals across the country; if successful, it may become a requirement for nursing graduates.

Developed over five years, and implemented in 2002 by the AACN and the University Health System Consortium, the program pairs recent BSN nursing hires with nursing mentors for a year in a universitybased hospital. This one-on-one relationship takes a commitment from the new graduate, the hospital and the nursing school dean, Rhome said.

"Data collected shows that it takes anywhere from six to 18 months for a [hospital] nurse to be confident and hit the floors running," Rhome said.

"If you're going to work in a hospital setting, you might have a two-week or two-year orientation program. It's all over the place," she added.

A post-baccalaureate program like the nurse residency program would standardize the orientation process.

Right now, new grad residencies are required for employment at these participating hospitals, none of which are in Georgia.

The program also includes monthly seminars for patient case studies.

Although it means more time on the front end, and dedicated nurse resources, "in the long run, this should provide better patient care," Rhome said.

Rhome is aware that pulling seasoned nurses from the floor to mentor new graduates can tax managers who already are hard-pressed to fill vacancies.

A group of hospitals that aren't part of the standardized residency program are balancing the study, Rhome said. Emory Hospital is part of this group.

"We want to see if the outcomes are any different with a residency program versus a hospital that doesn't have one," Rhome said.

Rhome is cautiously optimistic that the program will help improve patient care and nurse retention rates. "The first cohort has already gone through the program, and the turnover rate is much lower than before the hospitals started the residency program."