New G raduate Nurses in the
I n t e n s i v e C a re S e t t i n g
Preparing Them for Patient Death
Colette D. Baudoin, PhD (c), MSN, RN, OCN, CNEa,*,
Aimme Jo McCauley, DNP, MSN, RNb,
Alison H. Davis, PhD, RN, CNE, CHSEc
KEYWORDS
New graduate nurse Stress Intensive care setting Transition End-of-life care
Palliative care Residency programs
KEY POINTS
As student nurses transition to practicing nurses, many factors, including the practice
readiness gap, lead to burnout and high turnover rates.
The nursing shortage and recent COVID-19 pandemic has increased the need for new
graduate nurses to enter directly into critical care areas upon graduation.
Intensive care areas complicate the difficult transition process for new graduate nurses
with higher acuity patients and increased patient deaths.
Education regarding end-of-life care and palliative care for new graduate nurses in critical
care areas is needed to support new graduate nurse role transition.
End-of-life and palliative care education provided to new nurse graduates in intensive care
areas improves confidence, knowledge, and resilience, while improving patient outcomes.
INTRODUCTION
Nursing is consistently ranked as one of the most stressful professions in health care.1
Stress and burnout have been researched in nursing since the 1970s as a means to
retain nurses and impact the nursing shortage.1 Nurses consistently identify feelings
of being overworked, unable to meet the needs of their patients, inadequately pre-
pared, and unprepared to cope with patient deaths as sources of stress which impact
their careers. These sources of stress impact nurses in all stages of their careers,
a
School of Nursing, Louisiana State University Health Sciences Center New Orleans, 1900
Gravier Street, #417, New Orleans, LA 70112, USA; b School of Nursing, Louisiana State Uni-
versity Health Sciences Center New Orleans, 1900 Gravier Street, #5B7, New Orleans, LA 70112,
USA; c School of Nursing, Louisiana State University Health Sciences Center New Orleans, 1900
Gravier Street, #509, New Orleans, LA 70112, USA
* Corresponding author.
E-mail address:
Crit Care Nurs Clin N Am - (2021) -–-
https://doi.org/10.1016/j.cnc.2021.11.007 ccnursing.theclinics.com
0899-5885/21/ª 2021 Elsevier Inc. All rights reserved.
, 2 Baudoin et al
nationally and internationally.New graduate nurses (NGNs) are more vulnerable
because of various factors, most notably, the practice readiness gap.
HISTORY AND DEFINITIONS
Historically, the literature describes the transition period from student nurse to
registered general nurse or NGN as a stressful time in a nurse’s career.2,3 The initial
work experience of a NGN has been described as the sensation of experiencing a
reality shock.4 Reality shock was then defined as “the shock-like reaction that oc-
curs when an individual who has been reared and educated in that subculture of
nursing that is promulgated by schools of nursing suddenly discovers that nursing
as practiced in the world of work is not the same-it does not operate on the same
principles”.5
The phenomenon of student nurses transitioning to NGNs became more evident
during the United States’ response to the novel coronavirus disease 2019 (COVID-
19) pandemic. As the numbers of COVID-19 cases were increasing rapidly in hospi-
tals throughout the United States in March, April, and May of 2020, many student
nurses nearing graduation from nursing school were quickly recruited into intensive
care hospital settings as their first job as a NGN.6 Along with the usual stressors
experienced by NGNs, including learning hospital policies and procedures, roles, re-
sponsibilities, and complex tasks beyond the nurse generalists role that are required
to work in an intensive care setting, the additional stressors of a global pandemic,
staffing shortages, lack of personal protective equipment, and a mounting number
of critically ill patients, many of whom were infected with the highly contagious
COVID-19 virus, required these NGNs to perform their role on the health care
team as nurses who had only begun to understand, yet alone master, the complex
content and environment of the intensive care setting. Programs are in place to
assist NGNs to transition into their roles as nurses, such as new nurse residency pro-
grams and/or preceptor programs. During the COVID-19 pandemic, however, pre-
ceptors and fellow staff members were struggling themselves to cope with the
rapidly changing and uncertain environment.7
End-of-life and/or palliative care, especially surrounding communication, is another
stressor in the intensive care setting that NGNs must add to their responsibilities in
their new, intense work environment. The practice readiness gap is evident here as
schools of nursing focus on the care of patients throughout the lifespan, but not the
care of the dying patient. Death education should include palliative and end-of-life
care. Internationally, there are inconsistencies in death education for undergraduate
nurses including “quality, content, and approach.”
Many patients in the intensive care settings are nonverbal for numerous reasons and
the nurse must try to facilitate family communication and closure at the end of life for
these patients in nontraditional methods. Communication is a difficult task alone when
patients are ill. With the addition of the intensive care setting and/or the inability to
communicate, the end-of-life or palliative care patient has added complex needs
and the NGN is now facilitating family communications among themselves and the
health care team. Survey results note that 75% of frontline health care workers under
the age of 30 years reported a negative impact on their mental health since the begin-
ning of the COVID-19 pandemic with 69% reporting feeling “burned out.”9 With an
ever-present and looming nursing shortage, it is important to consider how NGNs
can be adequately supported to ensure their success and commitment to continue
their goals of working and succeeding in an intensive care setting. The burnout noted
surrounding end-of-life and palliative care patients is especially concerning and
I n t e n s i v e C a re S e t t i n g
Preparing Them for Patient Death
Colette D. Baudoin, PhD (c), MSN, RN, OCN, CNEa,*,
Aimme Jo McCauley, DNP, MSN, RNb,
Alison H. Davis, PhD, RN, CNE, CHSEc
KEYWORDS
New graduate nurse Stress Intensive care setting Transition End-of-life care
Palliative care Residency programs
KEY POINTS
As student nurses transition to practicing nurses, many factors, including the practice
readiness gap, lead to burnout and high turnover rates.
The nursing shortage and recent COVID-19 pandemic has increased the need for new
graduate nurses to enter directly into critical care areas upon graduation.
Intensive care areas complicate the difficult transition process for new graduate nurses
with higher acuity patients and increased patient deaths.
Education regarding end-of-life care and palliative care for new graduate nurses in critical
care areas is needed to support new graduate nurse role transition.
End-of-life and palliative care education provided to new nurse graduates in intensive care
areas improves confidence, knowledge, and resilience, while improving patient outcomes.
INTRODUCTION
Nursing is consistently ranked as one of the most stressful professions in health care.1
Stress and burnout have been researched in nursing since the 1970s as a means to
retain nurses and impact the nursing shortage.1 Nurses consistently identify feelings
of being overworked, unable to meet the needs of their patients, inadequately pre-
pared, and unprepared to cope with patient deaths as sources of stress which impact
their careers. These sources of stress impact nurses in all stages of their careers,
a
School of Nursing, Louisiana State University Health Sciences Center New Orleans, 1900
Gravier Street, #417, New Orleans, LA 70112, USA; b School of Nursing, Louisiana State Uni-
versity Health Sciences Center New Orleans, 1900 Gravier Street, #5B7, New Orleans, LA 70112,
USA; c School of Nursing, Louisiana State University Health Sciences Center New Orleans, 1900
Gravier Street, #509, New Orleans, LA 70112, USA
* Corresponding author.
E-mail address:
Crit Care Nurs Clin N Am - (2021) -–-
https://doi.org/10.1016/j.cnc.2021.11.007 ccnursing.theclinics.com
0899-5885/21/ª 2021 Elsevier Inc. All rights reserved.
, 2 Baudoin et al
nationally and internationally.New graduate nurses (NGNs) are more vulnerable
because of various factors, most notably, the practice readiness gap.
HISTORY AND DEFINITIONS
Historically, the literature describes the transition period from student nurse to
registered general nurse or NGN as a stressful time in a nurse’s career.2,3 The initial
work experience of a NGN has been described as the sensation of experiencing a
reality shock.4 Reality shock was then defined as “the shock-like reaction that oc-
curs when an individual who has been reared and educated in that subculture of
nursing that is promulgated by schools of nursing suddenly discovers that nursing
as practiced in the world of work is not the same-it does not operate on the same
principles”.5
The phenomenon of student nurses transitioning to NGNs became more evident
during the United States’ response to the novel coronavirus disease 2019 (COVID-
19) pandemic. As the numbers of COVID-19 cases were increasing rapidly in hospi-
tals throughout the United States in March, April, and May of 2020, many student
nurses nearing graduation from nursing school were quickly recruited into intensive
care hospital settings as their first job as a NGN.6 Along with the usual stressors
experienced by NGNs, including learning hospital policies and procedures, roles, re-
sponsibilities, and complex tasks beyond the nurse generalists role that are required
to work in an intensive care setting, the additional stressors of a global pandemic,
staffing shortages, lack of personal protective equipment, and a mounting number
of critically ill patients, many of whom were infected with the highly contagious
COVID-19 virus, required these NGNs to perform their role on the health care
team as nurses who had only begun to understand, yet alone master, the complex
content and environment of the intensive care setting. Programs are in place to
assist NGNs to transition into their roles as nurses, such as new nurse residency pro-
grams and/or preceptor programs. During the COVID-19 pandemic, however, pre-
ceptors and fellow staff members were struggling themselves to cope with the
rapidly changing and uncertain environment.7
End-of-life and/or palliative care, especially surrounding communication, is another
stressor in the intensive care setting that NGNs must add to their responsibilities in
their new, intense work environment. The practice readiness gap is evident here as
schools of nursing focus on the care of patients throughout the lifespan, but not the
care of the dying patient. Death education should include palliative and end-of-life
care. Internationally, there are inconsistencies in death education for undergraduate
nurses including “quality, content, and approach.”
Many patients in the intensive care settings are nonverbal for numerous reasons and
the nurse must try to facilitate family communication and closure at the end of life for
these patients in nontraditional methods. Communication is a difficult task alone when
patients are ill. With the addition of the intensive care setting and/or the inability to
communicate, the end-of-life or palliative care patient has added complex needs
and the NGN is now facilitating family communications among themselves and the
health care team. Survey results note that 75% of frontline health care workers under
the age of 30 years reported a negative impact on their mental health since the begin-
ning of the COVID-19 pandemic with 69% reporting feeling “burned out.”9 With an
ever-present and looming nursing shortage, it is important to consider how NGNs
can be adequately supported to ensure their success and commitment to continue
their goals of working and succeeding in an intensive care setting. The burnout noted
surrounding end-of-life and palliative care patients is especially concerning and
