Enhancing transition: An enhanced model of clinical placement for final year nursing students

Nurse Education Today (2009) 29, 48–56

Nurse Education Today www.elsevier.com/nedt

Enhancing transition: An enhanced model of clinical placement for final year nursing students Robyn Nash

a,1

, Pamela Lemcke

b,2

, Sandra Sacre

c,*

a

School of Nursing, Faculty of Health, Queensland University of Technology, Australia School of Nursing, Queensland University of Technology, Australia c Faculty of Health Office, O Block, Queensland University of Technology, Victoria Park Road, Kelvin Grove, Queensland 4059, Australia b

Accepted 24 June 2008

KEYWORDS Clinical Clinical Clinical Nursing

experience; placement; transition; transition

Summary Specialised support for student nurses making the transition to graduate nurse can be crucial to successful and smooth adjustment, and can create a path to positive and stable career experiences. This paper describes an enhanced model of final year nursing student placements which was trialled in 2006 at the Queensland University of Technology. The model involved collaboration with two major urban health services and resources were developed to support effective transition experiences. Ninety-two students, including 29 trial participants and 63 non-trial participants were assessed on preparedness for professional practice, before and after the trial semester. Results indicated an increase in preparedness across the entire sample, but students participating in the trial did not differ significantly in overall preparedness change from those who did not participate. Higher baseline preparedness in the trial group highlighted the possibility that proactive students who choose enrichment experiences tend to be likelier to gain benefit from such options than those who do not. Qualitative findings from focus groups conducted with 12 transition group students highlighted that one of the main beneficial aspects of the experience for students was the sense of belonging to a team that understood their learning needs and could work constructively with them. Crown Copyright c 2008 Published by Elsevier Ltd. All rights reserved.



* Corresponding author. Tel.: +61 7 31383022; fax: +61 7 31385662. E-mail addresses: [email protected] (R. Nash), p.lemcke@ qut.edu.au (P. Lemcke), [email protected] (S. Sacre). 1 Tel.: +61 7 3138 9748; fax: +61 7 3138 5662. 2 Tel.: +61 7 3138 3830; fax: +61 7 3138 3814.



Introduction Transitions have been defined as starting with an ending, followed by a period of confusion and distress, and leading to a new beginning ( Williams,

0260-6917/$ - see front matter Crown Copyright c 2008 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2008.06.004

Enhancing transition: An enhanced model 1999). A key point is that transitions result in transformation. Within the nursing profession, the transition from student to graduate nurse is a common rite of passage that marks the end of initial educational preparation in the discipline and the beginning of a professional journey as a nurse and member of the multidisciplinary health team. Ideally, the pre-transition process is one which enables pre-transition students to build their clinical confidence and consolidate their clinical skills, while also developing positive professional qualities and work attitudes. It is during this time that they will also begin to fully understand their prospective responsibilities as professionals, and comprehend the boundaries that define safe and ethical practice. Importantly, the experience of working closely with an experienced practicing nurse in a clinical setting has been shown to positively enhance transition beyond the formal educational preparation acquired at university (Cantrell and Browne, 2005). Thus, the organizational support afforded to pre-transition students as they look toward their professional nursing careers is critical to the success, or otherwise, of the transition process. This paper outlines some of the literature relating to transition models for nursing students and details an enhanced model of clinical placement that was trialled at the Queensland University of Technology in 2006 in collaboration with two large metropolitan hospitals. Students in the trial were surveyed and compared with those undertaking standard block placement with the purpose of investigating whether or not specialised support and resources aimed at enhancing transitional placements would lead to significantly different preparedness for professional practice.

Literature review The experience for nursing students of being in transition has been described as a ‘‘journey of beginning’’, a period of adjustments and stress and also of growth and differentiation ( Holland, 1999). These neophytes must learn the culture, language, rules, and practices of the healthcare environment (Cantrell and Browne, 2005; Walker, 1998). Initially, when encountering a new workplace culture and trying to be accepted within it, the transitional nurse is likely to feel uncomfortable, and he or she may experience feelings of inadequacy. Clinical placements allow students an opportunity to put theory into practice ( Elliot, 2002) and for this, and other reasons, the success of their entire program hinges largely on the effec-

49 tiveness of their clinical experiences (Pearcey and Elliott, 2004). Cantrell and Browne’s (2005) research has found that when the transitional nurses perceive themselves as being part of the work unit’s culture and patient care activities, they ‘‘came to believe that they were finally learning and experiencing the ‘true’ world of nursing’’ (p. 253). It is well known that the first 3–6 months of employment as a graduate nurse are among the most stressful in a nurse’s career (AUTC, 2002; Godinez et al., 1999), and the most critical in terms of their decision about whether or not to commit to a career in nursing (Greenwood, 2000; Marcum and West, 2004). Many new graduates experience reality shock, a ‘‘climate of conflict’’ created as they make the transition from one culture with a given set of values and ideals to another culture often with different, and even conflicting, values and ideals (Cantrell and Browne, 2005; Delaney, 2003; Kramer, 1974, 1985; Walker, 1998). It seems likely that this process is already beginning during the pre-transition period, when students may become more aware that their skill levels do not match their expectations of the role and responsibilities of a practicing registered nurse (Cantrell and Browne, 2005). Since this is the same period during which students are likely to experience feelings of self-doubt and discouragement, the quality of the transition experience may have important consequences, both for the nurse and for the workplace and nursing workforce. Research has found that a positive clinical learning environment is crucial for pre-transitional learning (AUTC, 2002; Greenwood, 2000; Dunn and Hansford, 1997; Henderson et al., 2006; Winter-Collins and McDaniel, 2000). A supportive clinical environment provides some of the most important learning opportunities for nursing students in terms of skills, knowledge, practice, reflection and cultural socialisation (Lee and French, 1997; Meyer et al., 2007; Thorell-Ekstrand and Bjorvell, 1995). It also allows the transitional nurse ‘‘to improve and consolidate their clinical skills and improve their patient management and time management in a context of provision, maintenance, and positive reinforcement and nurture ( AUTC, 2002, p. 194). Dunn and Hansford (1997) found that a positive, stimulating and supportive environment resulted in higher student satisfaction, but also that more proactive, satisfied students were better at achieving a more effective clinical placement experience. It was also found that the most influential factor in producing a positive clinical learning environment was the registered nursing ward staff. Papp et al. (2003) and

50 Chan (2001) have also found that good ward atmosphere, inclusion of students as colleagues, democratic patient allocation and good cooperation of ward staff predicted a positive clinical learning environment. Another study (Hart and Rotem, 1994) found that students’ need to belong and be accepted and recognised for their contribution to patient care was important. Chan (2001) found that students value support, respect and recognition from clinicians above all other factors in the clinical learning environment. Other important factors have been shown to include: supernumerary time, allocated time with relevant teams or departments, and time spent with competency assessors (Meyer et al., 2007). Although nursing students perceive the clinical environment as the most influential context for gaining skills and knowledge, many nursing students feel threatened by the prospect of learning in the clinical area (Campbell et al., 1994; Chan, 2001, 2002). In the clinical environment, it can also be difficult for the student nurse to differentiate between their role of learner and worker (Melia, 1987) and they may struggle with the short-term character of their membership of the patient care team (Ashworth and Morrison, 1989). For pre-transitional students, this tension is likely to be more pronounced. They are in the process of forming impressions about the likelihood of receiving the support that they feel they will need in the transitional period. Positive learning experiences in a supportive work environment during pre-transition, therefore, will assure them that they will be able to successfully negotiate the full transition to professional practice.

The current project This study developed, trialled and evaluated a collaborative model of clinical placement which focused on the transition of final year undergraduate nursing students to practice as registered nurses. It aimed to improve transition-to-practice for final year nursing students through enhanced placement processes for students and registered nurse supervisors at two Brisbane hospitals. The project encompassed two main objectives. The first was to collaborate with workplace representatives in the development of clinical placement models to facilitate effective transition of final year students to professional practice. The second objective was to develop capacity building resources for students and supervisors to support effective transition experiences.

R. Nash et al.

Key strategies One of the main strategies of the project was to work collaboratively with representatives from the two participating hospitals to develop and implement re-conceptualised ‘transition’ models of clinical experience for final year students. A second strategy was to develop a set of resources to support effective transition experiences for final year students and their registered nurse supervisors. The project was undertaken over the course of Semester 1 and Semester 2, 2006, in conjunction with the final year clinical practicum units in these semesters. Altogether, it involved a little over 25% of the final semester student cohort of 404 students, nine industry representatives and more than 100 registered nurse supervisors. At the southern hospital, these RNs were hospital-employed preceptors, supported by a university-based facilitator. At the northern hospital, the RNs were either hospital-employed facilitators seconded by the university or university-based facilitators.

Developing re-conceptualised transition models of clinical experience The development of re-conceptualised models of transition experience was achieved through a series of discussions involving the academic and industry stakeholders in this project. The conversations included a review of the current clinical support mechanisms operating at the two hospitals, their aspirations regarding improved transition experiences for both students and staff, local drivers and/or barriers to be considered, the importance of working collaboratively to potentially achieve a ‘win–win’ for all stakeholder groups. There were slightly different themes at the two hospitals in the dialogue that emerged and, in the main, these reflected the varying priorities, issues and/or processes relevant to each of the hospitals involved in the project. However, to facilitate consistency with respect to the project, the discussions at both hospitals were underpinned by a common set of concepts. These included conceptualisation of the final year clinical experience from a pre-transition perspective and working with students on a more explicitly collegial basis. Different transition models were developed for each of the two hospital services that collaborated on this project. At the southern hospital, key features of the model that was developed and implemented during the project included:

Enhancing transition: An enhanced model preceptorship on a 1:1 basis, rotation through three general and/or specialty clinical areas of the Adult, Children’s’ and Women’s’ Hospitals, and flexible rostering across seven days and all shifts (including a maximum of three nights of night duty across each clinical block). At the northern hospital, the model included: modified preceptorship using ward-based clinical mentors (building on the Clinical Education Unit model of clinical education used there), and flexible rostering across seven days and all shifts (including a maximum of three nights of night duty). At both hospitals, students were also included in facilitywide and ward-based events, such as Staff Development activities, which were taking place within the organization. Final year students undergoing placement at locations other than these facilities (i.e., non-transition model students) experienced standard block placements (3 · 4 weeks, 5 days per week) with group facilitation by supernumerary registered nurses (some seconded hospitalemployed registered nurses and some universityemployed registered nurses). Each clinical facilitator supported 6–12 (mode = 8) students in their block placement learning.

Development of resources to support effective transition experiences for final year students The resources developed to support students included digital stories which talk about the journey from beginning to final year nursing student through the voices of three third year students. The digital stories aimed to: promote deeper understandings with respect to transition to professional practice through sharing the personal experiences of peers; engender a sense of community among final year students ( Ironside, 1999, 2003); and consistent with Lapadat’s (2004) view that education is the construction and reconstruction of personal and social stories, provide personally contextualized opportunities that would stimulate other students to reflect on their beliefs, attitudes, feelings and values regarding impending transition to professional practice (Leshem and Trafford, 2006). These resources are now available to students in the Bachelor of Nursing course, and their workplace supervisors, through the Faculty of Health’s Work Integrated Learning (WIL) site. They are accompanied by sets of reflective triggers designed for the respective types of users and, since 2007, have been incorporated into pre-briefings that are held prior to commencement of the final two clinical practicums.

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Development of resources for registered nurse supervisors The resources developed to support registered nurse supervisors included a set of four self-directed modules entitled the ‘Supporting Transitions to Professional Practice (STePP) Preceptorship’ Program. The program was developed in consultation with staff in two participating hospitals to enhance the support given by registered nurses to students during the ‘pre-transition’ period of their professional careers. The program was designed to complement the preceptorship and/or orientation programs already operating locally within the two hospitals. Its main purpose was to enhance the knowledge and skills of registered nurses with respect to precepting undergraduate nursing students during the pre-transition period of their program. Each module contains a set of selected readings and learning activities exploring four key themes related to preceptorship and the support of pre-transition nursing students. On successful completion of a specified assessment package, participants are also able to apply for academic credit within the Graduate Diploma of Nursing or the Graduate Certificate of Health Science courses at QUT. In addition to the resources described above, a series of six workshops (four at the southern hospital and two at the northern hospital) were conducted over the course of the year for registered nurses who were working with ‘Transition’ students. The core themes which formed the basis of the workshop content complemented the key concepts developed within the STePP modules (referred to earlier). Altogether, a total of 170 RNs attended these workshops.

Method Participants Information about the transitions model was provided to the final year student cohort at the beginning of the university year when these students were providing their placement preferences. From a cohort of 404 final semester students, 92 students participated in the survey at both the start and end of semester. Just under one third (N = 29) identified as participating in the transitions program. Of these, nine participated in the program at the southern hospital, 17 participated at the northern hospital, and three did not specify where they participated. The remain-

52 der of the group (N = 63) participated in the standard block clinical placement. Participants were recruited to complete the surveys at the end of one of their university classes. They were given written and verbal information about the purposes of the study at this time. They were also invited to participate in focus groups which were held on campus on subsequent days. Focus groups (two) were held with 15 final year, transition group students (six from the southern hospital and nine from the northern hospital) prior to, and following their first practicum for the year (Clinical Practicum 4), to explore their perceptions and opinions in relation to the transition model of placement that they had experienced. These participants were invited back to participate in follow-up focus groups that were held again in conjunction with the final practicum in Semester 2. Separate focus groups (four) were conducted with nine industry representatives and 12 registered nurses (six facilitators and six preceptors) to explore their perceptions of the transition model as it had been implemented.

Measures Student participants in the transitions project were invited to complete the Preparedness for Graduate Nursing Practice Questionnaire both prior to, and following, their final eight week clinical placement in Semester 2, 2006. The questionnaire was adapted from the Preparation for Hospital Practice Questionnaire (Hill et al., 1998). This scale consisted of 23 items (see Table 1) with likert scale response choices ranging from 1 (very unable) to 6 (very able). Student focus group questions were open-ended: ‘How was this transition model of placement different for you from previous placement experiences?’ and ‘What were the advantages and disadvantages of this style of placement?’ The same questions were used in the focus groups involving industry partners, facilitators and preceptors.

Ethical considerations The data were collected as a matter of routine quality control procedures that are in place to monitor the value of innovations and initiatives that are introduced to the university’s courses. Data collection procedures were in accordance with the NHMRC (2007) guidelines for ethical human research: Students were informed that their

R. Nash et al. participation was voluntary and that no identifying information would be collected or recorded; verbal consent was obtained; anonymity was assured and maintained; no burden or risk was imposed on students; no coercion or pressure was applied; and students were advised they could withdraw from the study at any time without suffering any disadvantage as a result of their decision. Students were invited to complete the questionnaire and/or participate in the focus groups in order to provide feedback about their clinical placement experience. The study did not meet the criteria for requiring formal ethical approval from either the university or hospital ethics committee and approval was granted at a local level.

Results Quantitative outcomes Paired samples t-tests were conducted to compare mean responses at the start and end of semester, with the significance level set at p < .002 to control for study-wise type 1 error. Across the semester, these analyses for the whole sample indicated an increase in preparedness across all of the 23 items, with this increase being significant on all but four items (see Table 1). Scores on each of the 23 items were added to give a total preparedness score at baseline and follow-up for each participant. In addition, total baseline scores were subtracted from total follow-up scores to give a change score for each participant. Oneway analyses of variance (ANOVA) were conducted to assess whether there were any differences between the transitions groups (southern hospital transition, northern hospital transition, not stated transition) and those who participated in the standard placement, in terms of total baseline or follow-up preparedness scores, or change in preparedness scores over the semester. The results of these omnibus analyses indicated that there was no significant difference between the four groups (southern hospital transition, northern hospital transition, not stated transition, and standard placement) on total baseline preparedness, F (3, 88) = 1.00, p = .396; follow-up preparedness, F (3, 88) = .40, p = .750, or preparedness change across the semester, F (3, 88) = 1.10, p = .351. Despite the non-significant findings, there was a trend for the transitions students to feel more prepared for clinical practice at both time points (see Table 2).

Enhancing transition: An enhanced model Table 1

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Mean scores on preparedness for graduate nursing practice, at the start and end of the semester (N = 92) Start semester M

I feel able to cope with prac I feel able to carry out nursing procedures like those that will be expected of me as a registered nurse I feel able to discuss health issues with patients I feel that I could handle an emergency nursing situation I feel able to recognise my own clinical limitations I feel able to assess the health needs of a new patient I feel able to plan the nursing care required for an assigned patient/group of patients I feel able to understand the application of basic sciences to clinical conditions I feel able to understand and observe for the actions, interactions and adverse effects of prescribed drugs I feel able to incorporate research and/or other evidence within my clinical decision I feel able to remain calm in difficult situations I feel able to assist and counsel a distraught patient and/or other family members I feel able to record clinical data systematically I feel able to reflect critically on my practice I feel able to be sensitive to the needs of other nursing staff I feel able to treat the patient as a whole person I feel able to coordinate patient management with medical and other allied health professionals I feel able to confidently approach more senior staff for help I feel able to continually evaluate my own clinical performance I feel able to identify my own educational needs I feel able to approach others in the ward regarding my learning Needs I feel eager to become a registered nurse I feel confident in my clinical nursing skills and abilities *

End semester

SD

M

SD

t

Sig. (2-tailed)

4.56 4.18

1.16 1.02

5.20 4.70

.88 .85

4.77 4.45

.000* .000*

4.13 3.39 5.06 4.04 4.07

.99 1.14 .93 1.01 1.02

4.70 3.89 5.42 4.64 4.95

.85 1.15 .74 .96 1.03

5.80 3.93 3.29 5.82 6.96

.000* .000* .001* .000* .000*

4.31

.94

4.79

.89

4.15

.000*

3.97

.99

4.51

1.02

4.36

.000*

4.17

.97

4.80

1.07

4.68

.000*

4.36 3.98

1.01 .98

4.75 4.44

1.00 .90

3.41 4.04

.001* .000*

4.70 4.69 4.95 5.02 4.23

.94 .92 .85 .91 .99

5.08 5.43 5.43 5.46 4.78

.93 .81 .81 .81 .95

3.20 4.30 4.98 4.43 4.64

.002 .000* .000* .000* .000*

4.72 4.78

.95 .89

5.23 5.10

.89 .84

4.47 2.81

.000* .006

4.95 4.78

.91 .91

5.32 5.20

.78 .94

3.09 3.94

.003 .000*

5.11 4.18

1.09 1.16

5.23 4.74

.99 1.08

1.21 4.27

.228 .000*

p < .002.

Table 2 Mean total preparedness scores for trial transitions groups and non-transitions group at baseline and follow-up Total preparedness

Transition (southern hospital) n=9

Transition (northern hospital) n = 17

Transition (not stated) n=3

Non-transition n = 63

Baseline M (SD) Follow-up M (SD) Change M (SD)

96.55 (17.80) 117.44 (10.85) 20.88 (15.07)

105.14 (14.98) 114.82 (13.15) 9.67 (10.29)

113.00 (19.31) 119.00 (4.00) 6.00 (21.00)

102.06 (16.04) 112.56 (17.50) 10.50 (18.85

Qualitative outcomes: perceptions of students regarding transition and supervisory support during this process Key themes that emerged from the student focus group discussions included:

Growing in confidence and competence Students spoke strongly about the perceived importance of having the knowledge and skills for practice as registered nurses and feeling confident in their ability to apply these within the clinical context. It was also evident that, in general, they had

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very high expectations of themselves which were not based on any particular data or evidence. Not too surprisingly, this was still a strong theme in their comments at the conclusion of the final practicum. However, while some students spoke about feeling scared at the prospect of becoming an RN, the more common view was that this was not necessarily a bad thing and, although there was still heaps to learn, they were ready to do it. The overall culminating view is perhaps best summed up by the following comment from one of the students: It was great – I’ ve learned to think like a nurse Becoming part of the team Almost without exception, students felt accepted as part of the various clinical teams in the areas that they were placed. Comments such as it was great – they (the RNs) shared their knowledge and experience with us, I really felt part of the team, my preceptor and I worked together and I was considered more a part of the ward team exemplify the positive views expressed by students. Apart from the social, cultural, etc. advantages which accrue from being part of the team, for some students at least there was also a positive impact on learning outcomes. As put by one student: Working alongside the same staff members was a lot harder to ‘bluff’ my way through prac. My knowledge and skill deficits were identified and people worked with me to improve in these areas. Experiencing the ‘real world’ of nursing practice Students highlighted the importance, for them, of experiencing the real world of nursing. Although they had all completed three clinical practicums as part of their earlier course experience, the perception that they needed more experience in the real world was very strong. In part, this perception related to the perceived need to feel competent and confident in relation to their practice (as described above). However, it extended beyond this to include finding out what shift work, night duty and working weekends was really like, attending staff in-services and, importantly, learning to cope with the day-to-day demands of working shifts as a nurse. Due to work and other commitments a number of students found it tough to do some nights and weekends as part of their Transition placement. However, the opportunity was highly appreciated and, as shown by the following comments,

those who did experience a full roster found it an invaluable experience: I felt sleep deprived doing lates, earlies and weekends but I learned to cope – it was good. I’ve had a real taste of what nursing is like now. I‘ve got an insight into what the nursing lifestyle is like. I feel more ready to take it on. Doing nights takes away the uncertainty of not knowing what it’s like. I feel OK about doing that now. Perceptions of industry supervisors and registered nurses Focus groups were also held with registered nurses and industry representatives from the two participating hospitals. Two key themes that emerged from these discussions were: Stepping back A consistent theme in the discussions with registered nurse and industry representatives was the notion of RN supervisors stepping back and allowing Transition students, where possible, to take the lead in terms of the delivery of patient care. This was recognised as an important part of students’ pre-transition experience and development. However, at the same time, important issues such as those of patient safety, patient acuity, level of student ability etc. were acknowledged as needing to be balanced with the opportunity for students to take greater responsibility with regard to care delivery. Nevertheless there was a strong perception that there was a good deal of scope for RNs to view the Transition practicums in a different way to those in the first and second year of the Bachelor of Nursing course. The general view was that, wherever possible, it would be beneficial for RNs to work on a more collegial rather than supervisory basis with students in this final year of nursing preparation. A related issue within these discussions was that of the RNs’ expectations of students. The importance of RNs retaining realistic perceptions of students’ performance within this stepping back – taking the lead scenario was acknowledged and the need for ongoing support with the enactment of this newer role was emphasized. Feeling it’s worthwhile Consistent with the above, industry stakeholders felt that participation in the transition initiative needed to have added-value for them as well as good outcomes for the students. In the main they felt that the potential advantages of this initiative for industry included: improved cultural and work

Enhancing transition: An enhanced model readiness of students for practice as new graduates; recruitment of organizationally savvy new graduate nurses; and further professional development opportunities for their staff. Support for RN staff Notably, the issue of support for staff involved in the transition initiative was strongly identified by industry representatives. The notion of face-toface workshops provided on-site by the university and complemented by self-directed study modules that could potentially by used by staff to gain academic credit was strongly endorsed. During the second semester the workshops were complemented at the southern hospital by the addition of a liaison facilitator who was employed for 1 day/week throughout the 8 week clinical practicum to provided 1:1 support for RN preceptors. The need for this additional strategy was a key point identified in the interim feedback received from RNs and industry representatives at this facility. The same issue was not identified at the northern hospital mostly likely because a liaison facilitator is already in place within this organization.

Discussion The current project involved the development, trial, and evaluation of an enhanced model of clinical placement for students about to make the transition from final year undergraduates to practicing registered nurses. This was achieved through collaboration with workplace representatives and the provision of specialised support in terms resources to support transition students and their clinical supervisors. The model was trialled in 2006, resulting in new awareness and understanding of some of the dynamics of the transition process from nursing student to graduate nurse. The non-significant trend for transition students to rate more highly on preparedness for clinical practice at baseline and follow-up was perhaps an indication that these students were more likely to self-select experiences which would provide career advantages and enrichment. This would be consistent with the findings of Dunn and Hansford (1997) that more proactive, satisfied students were better at achieving a more effective clinical placement experience. It must also be acknowledged that the sample size was small, which may also have resulted in insufficient power to detect an effect. Focus group findings indicated that the model did enhance the transition experience, and also highlighted the fact that students who nominate themselves for enrichment experiences are often those who gain the

55 most benefit. Similarly, Henderson et al. (2006) found that students at more advanced levels achieved higher levels of involvement, satisfaction, innovation, individualisation, personalisation and task orientation during their clinical placements. The findings of this study underscore the importance of matching students to placement models. The enhanced transition model which allowed students more autonomy and responsibility was successful for the students who chose the enrichment experience over standard block placement. Their preparedness for professional practice increased in the same way that non-transition students’ preparedness did, but this type of placement model may not have suited everyone. For example, the AUTC (2002) survey found that for 64% of respondents, the worst aspect of their transition experience was the feeling of being ‘‘thrown in at the deep end to sink or swim’’. Yet other confident graduates felt frustrated that they were not allowed to make decisions about patient care. This highlights the importance of assessing confidence and competence, as well as challenging without extending transitional nurses beyond their capacity. This study confirms that students need to know what their transition placement options are so that they can apply for the style of placement model that most suits their learning style and needs.

Conclusion Key findings of the current project related to those aspects of the experience which the students found particularly beneficial in enhancing the transition process. Consistent with previous findings, the results of the current trial indicated the importance of a positive and supportive clinical learning environment. In particular, students highlighted the importance to their learning of belonging to a team where their skills and knowledge could be constructively improved. The findings indicated no significant differences in preparedness for practice between students who experienced the enhanced transition placement and those who experienced the standard facilitated block placement. However, the students who elected for the enhanced model tended to be more confident at baseline, suggesting that the model was better suited for particular types of students who sought more challenging styles of clinical experiences. It is recommended that detailed studies are conducted to assess which students characteristics are better matched to

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enhanced transitional models of transitional placement, and that students are encouraged to consider their preferred learning styles when applying for final year placements.

Acknowledgement The work involved in this initiative was funded by a QUT Large Teaching and Learning Grant.

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