Program Profile

The Unique Value of Externships to Nursing Education and Health Care Organizations

Nursing students who participated in the VALOR externship felt confident in their clinical skills when they were transitioning to the RN role.

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New nurse graduates often have difficulty transitioning to the role of registered nurse (RN).1 Given the complexity of the health care environment, the need is growing to prepare nursing students for nursing practice. Although nursing education provides students with a basis for practice, school alone cannot prepare them for actual practice in the hospital setting.2 Compared with nurse residency programs, which provide extended postlicensure training, the national Veterans Affairs Learning Opportunity Residency (VALOR) program provides externships independent of nursing school. Externships allow students to train in a hospital setting (generally during the summer months) before becoming a licensed RN. Nursing students who are entering their senior year of coursework in a bachelor of science nursing program and who have a minimum 3.0 grade point average can apply for this competitive national scholarship offered at VAMCs. The VALOR program is a paid learning opportunity, and students gain hands-on clinical experience under the guidance of preceptors.

Little externship research exists in the nursing literature.3,4 The authors conducted the present study to help fill the gaps in the literature and to add to the only other study findings on VALOR.3 This program, started in 1990 to aid in nursing recruitment and retention, offers students early exposure to the complexities of nursing practice.

The authors investigated RNs’ experience in the VALOR prelicensure externship during the nurses’ senior year of coursework and the impact of this experience on their nursing practice. The program offers 800 hours of hospital-based experience outside the classroom. New nurses who gained only limited clinical exposure in nursing school may feel insecure about their clinical skills.5 Casey and colleagues found that students want more clinical experience than offered by nursing school practicums.6 The VALOR participants obtain additional clinical time, which contributes to their self-confidence when transitioning to the RN role.7

Literature Review

New graduate nurses work in complex health care environments with unfamiliar technologies, shift hours, heavy patient loads, psychological and professional stressors, socialization problems, and patient safety issues.8 They often are unable to connect their educational experience with the realities of practice and find the work environment incongruent with their nursing school education.9 Although new nurses’ difficulty in transitioning to their professional role has been addressed in the literature, transitional experience has not improved.10 Studies have found that new graduate nurses want more support than is given and have suggested that unfamiliar workplace dynamics create stress for new nurses.11

Anxiety, insecurity, and fear of failure are associated with the transition from student to practicing nurse.10 Because of the additional clinical experience gained in an externship, students likely are more self-confident when they assume the RN role.12 White suggested self-confident students see themselves as nurses and feel capable of caring for patients.13 Externship experience makes the transition to professional nursing less stressful, because externship students obtain an inside view of nursing culture.14 Students increase their understanding of nurses’ multiple roles and responsibilities, because these programs focus on increasing clinical skills and competency.15 To perform successfully as RNs, new graduates need competencies and knowledge beyond those obtained in nursing school.16

In the nursing profession, an association between job satisfaction and turnover exists.17,18 Of new graduate nurses, 35% to 69% leave their position within the first year of employment.19 Replacing nurses reduces hospital productivity and efficiency and increases cost.20 New graduate nurses leave because they are dissatisfied with and overwhelmed by the complexity of the work environment.21 Prelicensure nurse externships can aid in recruiting and retaining new graduate nurses for the hospitals that host these programs.22 For host facilities, recruitment rates of 50% to 79% have been reported.23,24

In a quantitative study, Nuttall surveyed 133 RNs about job satisfaction, role socialization, professionalism, and sense of belonging.3 Of these RNs, 34 had participated in VALOR and 99 had not. There was no evidence that the RNs with VALOR experience had a higher degree of professionalism, job satisfaction, or role socialization; only sense of belonging (age-adjusted) was higher for the VALOR group. The conflicting data on prelicensure externship outcomes call for further analysis of these programs.3 Nuttall noted that her study “was the first... to evaluate the VALOR program and future research [using a qualitative approach] is needed to identify additional outcomes related to this program.”3


This study using hermeneutic phenomenology was approved by the Salem VAMC in Virginia and by the institutional review board at Nova Southeastern University.24 Study participants provided written informed consent before being interviewed.


Nurses in the VALOR externship in 2011 and 2012 were contacted. Study inclusion criteria were participation in the summer portion of VALOR, current full-time or part-time RN employment, and licensed nursing experience of at least 3 months but not more than 2 years. Researchers suggest that a new graduate nurse has less than 2 years’ experience.25 Interviewees were from California, Florida, North Carolina, Virginia, and West Virginia. Employment at a VAMC was not a study requirement (Table).


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