Faculty of Medicine and Health Sciences Universiti Malaysia Sarawak Bachelor of Nursing Programme 2011/2012

MDJ 4402 Nursing Management

Reality Shock
The Experience of Transition from Student Nurse to Registered Nurse
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Prepared by: Jr Brian Hogan Paulus (matric no: 20570) Lecturer: Mr Rekaya Vincent Balang

Assignment Topic

Transition is a complicated process whereby many changes might occur at once. The newly graduated nurse tries to juggle all the changes which may cause him or her to face reality shock. Discuss this issue. What are the strategies that could ease this issue?

Presentation Overview
1 2
3 4 5 6
What is Reality Shock How Reality Shock Emerges

Transition Stages during Reality Shock

Causes of Reality Shock Consequences of Reality Shock Strategies to Reduce Reality Shock
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What is Reality Shock?

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Definition of Terms
Reality = The state of being real Shock = A disturbance in the equilibrium or permanence of something (Merriam-Webster, 2012)

Hence generally,
Reality Shock = The disturbance in the equilibrium of reality

In nursing perspective: Reality shock is the shocking experience of new graduate nurses when they realise that the work situation for which they have prepared for DOES NOT exactly operate within the values and ideals that they had anticipated. (Meleis, 2010)

This phenomenon emerges as the experience of transition from being a nursing student to a registered nurse. (Duchscher, 2008)

How Reality Shock Emerges

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How Reality Shock Emerges

When a new graduate nurse starts working as a registered nurse, he or she would undergo experiences encompassing four main aspects: 1) Relationships 2) Roles Expectations 3) Responsibilities 4) Knowledge

REALITY SHOCK!!!

Reality

Expectations

-Family/friends/intimates -Practice -Critical decision making and clinical judgement expectations -Home/Work balance -Financial management -Changing roles and task -Leadership/Delegation -Sociocultural assimilation

-Personal/professional relationships -Intergenerational dynamics -Intradisciplinary/ interdisciplinary relations -Social -Life changes
maturity

Responsibilities

-Interdisciplinary/Intra-disciplinary -Performance expectations -Roles and responsibilities -Personal/professional self -Professional culture

-Skills and task

Relationships
-Professional culture; peer support -Developmental task -Leadership and collaboration skills
-Organisational structure -Role blurring

TRANSITION Transition from student nurse toSHOCK nurse registered

Knowledge
-Nursing as a profession -Relational dynamics -Transition experience -Intellectual/Practical/ Theoretical/Tacit

-Professional roles

Roles

-Role stress/strain -Practice autonomy -Developing personal identity

Slide 10

-Critical decision making and clinical judgement expectations -Role confusion/ambivalence

-Life roles Transition Shock Model (Duchscher, 2008)

Stages of Transition Shock

Stages of Transition Shock are explained as a nurses orientation towards the new role as a registered nurse 11

Months of practice 1 2 3 4 5 6 7 8 and afterwards

DOING: Learning Performing Concealing Adjusting Accommodating

BEING: Searching Examining Doubting Questioning Revealing

KNOWING: Separating Recovering Exploring Critiquing Accepting

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Transition Stages Model (Duchscher, 2008)

Causes of Reality Shock

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Unfamiliar environment

Emotional Distress

Different sociocultural setting

Causes of Reality shock

Inadequate experience Knowledge and skills gap
(Bowles & Candela, 2005; Duchscher, 2008; Harwood, 2011; Hinton & Chirgwin, 2009; OShea & Kelly, 2006)

Increased accountability

Unfamiliar Environment and Socio-cultural Setting

Meet with new environment and socio-cultural setting.

New environment different than student environment.

The culture of the patient e.g.: high demand

Stressful.

Work together. Need to accept each other.

(Bowles & Candela, 2005; Duchscher, 2008)

Increased Accountability
Unclear practice expectation

Professional accountability

Need to complete task given

Stressful

(Duchscher, 2008)

Knowledge and Skills Gap

Theory-practice gap issue

Theory-based education and clinical placement are separated

Subject and assessment are different from what was learnt / out of date

Lack of critical thinking

(Hinton & Chirgwin, 2009)

Inadequate Experience

Increasing of nursing students

Limited place for clinical placement

Student has short time for clinical placement

Lack of real clinical experience

Not enough time for adapt to clinical area

(Harwood, 2011; Hinton & Chirgwin, 2009)

Emotional Distress
New environment

Distress, frightening, low self esteem

New social cultural

Increased accountability

Lack of experience

Lack of knowledge
(OShea & Kelly, 2006)

Consequences of Reality Shock

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Negative Consequences
High level of stress

Leave profession

Frustration and guilt Subsequent powerlessness; fatigued, debilitating Detrimental effects on nursing care; technical, task-driven, largely unsatisfying
(Ambler, 1995; Banks & Bailey, 2010; Bowles & Candela, 2005; Cowan & HengstbergerSims, 2006; Bueno, 1995; Duchscher, 2008; Hodges et al., 2008; Horsburgh, 1989; Kelly, 1998; Kilstoff & Rochester, 2004; Stacey & Hardy, 2011; Walker, 1998)

Positive Consequences
Motivation of nurses

Job satisfaction
Evolution of a more mature, professional sense of self
Banks & Bailey, 2010; Duchsher, 2008; Halfer & Graf, 2006

Strategies to Reduce Reality Shock

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Strategies to Reduce Reality Shock

Transition Modules

Nurse Residency Programme

Managers support and mentorship

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Transition Modules
Integrating key components in real practical setting in the final modules of training. Developed by clinical education team of hospital and tutors in university. Initially implemented by universities in Canada with collaboration from local hospitals. Aimed to support new staff nurses during their first 6 months following qualification
Source: Broad, Walker, Boden & Barnes (2011)

Transition Modules: Highlights

Prioritization of patients care and confidence issues especially medicines management.

Practical issues such as medical equipment safety

Successful transition
Basic life support

Planning and organization of patients care

Source: Broad, Walker, Boden & Barnes (2011)

Transition Modules: Outcome

Increase in confidence & competence in commencing their new role, they feel more positive

Graduates Employing hospital

Employees more likely to remain in profession - more cost effective Better contribution to patients care

Source: Broad, Walker, Boden & Barnes (2011)

Nurse Residency Program

Start being implemented in Children Hospital Los Angeles and followed by another 35 Hospitals in States Lasting for about one year. Group of 6 to 10 nurses meet monthly for a 4 hour session in which they share tales from bed side facilitated by an expert nurse. It help graduate nurses to: Solve problem that they are experiencing out in their units. Learn a concise way to give patient report to doctor ,delegate tasks and think critically. Bond socially
Most of us were stressed but when we told our stories, we laughed & you could feel the tension going out of the room. It helps you realize you are not alone.
Source: Thrall, 2007

Nurse Residency Program Nurse Residency Program... why hospitals are starting it?
Increase level of new graduate nurses preparedness to become staff nurse

Nurse Residency Program

Percentage of hospitals in States reporting new graduates definitely prepared to provide safe and effective care Diploma Bachelor Degree

47%

41%

Source: National Council of State Board of Nursing 2003 Employer Survey, 2004.

Percentage of new graduate reporting education adequately preparing them to... Statement Provide direct care to 6 or more patients Know when and how to call a physician Synthesize data from multiple source in making decision Delegate to other RNs and assistive personnel Manage time, organize workload and prioritize tasks Appropriately utilizing research finding in providing care Percentage 22% 42% 50% 32% 47% 48%

Source: National Council of State Board of Nursing, Practice and Professional Issues Survey, Fall 2004 & 2006.

Nurse Residency Program: Outcome

Nurses become better at asking the right questions, pulling together needed data, realizing what fit and what doesnt and where to find resource they need. Moreover, through this program, they are better equipped to start assignments in specialized unit such as critical care rather than start on medical-surgical unit and work their way into more complex care United States had started this program since 1999. Children Hospital Los Angeles had implemented the Nurse Residency Program and found out that from 1999 to 2007, the average turnover rate of graduates had dropped drastically.

Turnover rate for new graduate nurses

Before implementation of the program After implementation of the program

12 month 24 month
36% 7% 56% 12.6%

Source: Thrall, 2007

Nurse Residency Program

What draw this program back?
Lack of time Lack of experienced nurses to teach, mentor and track the new graduate nurses. Cost a lot- pay for facilitator & educator, for graduate nurses during course time etc.
Source: Thrall, 2007

Managers Support and Mentorship

A good manager should: Be accessible Be visible Practice clear and transparent communication Enact evidence based practice Frequently check in with new graduates. Supports includes: - Formal orientation - Arrange work scheduled in a way that it adapted so that new graduates are supported by the experienced staffs.
Source: Morrow, 2008

Mentorship
Mentor can share their experience about some real life problem and stress mgmt with the new graduates such as how to promote effective when working a night schedule . Is a win-win relationship where senior staff nurse also improve leadership skills, professional relationship, learn problem solving skills which lead to job satisfaction Includes:
i. ii. introduction to practice environment overt and covert culture
Source: Alspach, 2006; Morrow, 2008

Mentorship includes...
Practice environment Reflection

Personalize team by creating who we are bulletin board

Method that bring mentor back in time to their novice stage are helpful for the new graduates

Experience nurses need to demonstrate maturity with conflict management. Exp: teachable moment vs. talking behind graduate nurses back Inside joke may lead to unintended misinterpretation by the graduates

Prior to the arrival of new graduates on the unit, manager can engage front line nurses in a discussion about their own lived experiences as new graduate. Was this a positive experience? Has eating our young ever been acceptable? If so, why and how can it be change?

Source: Dracup & Bryan-Brown, 2004; Morrow 2008

Conclusion
New nurses face great challenges when they undergo the transition from student nurse to registered nurse. The challenges arise due to the reality which differs from the new graduate nurses expectation. When the reality is different, the situation demands adaptation. The adaptation is seen as the new graduate nurses orientation to the reality.

Different nurses have different level of ability to adapt, which requires time varying from a nurse to another.
Successful adaptation could produce positive outcome to the nurses whilst failure to adapt causes negative impacts to nurses and nursing profession. To solve the negative impact caused by reality shock, new graduate nurses needs to prepare themselves physically, intellectually, emotionally, and socioculturally.

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Slides prepared by Jr Brian Hogan

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References Ambler, N. (1995). The beginning practitioner: 1st year RN adaptation to the workplace. Paper read at Conference Proceedings Research for Practice, at Newcastle University. Banks, Z. M., & Bailey, J. H. (2010). Career motivation in newly licensed registered nurses: What makes them remain. The Qualitative Report, 15(6), 1489-1503. Retrieved from http://www.nova.edu/ssss/QR/QR15-6/banks.pdf Bowles C. & Candela L. (2005). First job experiences of recent RN graduates. Journal of Nursing Administration, 35(3), 130137. Broad, P., Walker, J., Boden, R., & Barnes, A. (2011). Developing a model of transition prior to preceptorship. British Journal of Nursing, 20, 20. Bueno, D. (1995). Ready, willing, able? Staff competence in workplace design. Journal of Nursing Administration, 22, 14-16. Cowan, L. S. & Hengstberger-Sims, C. (2006). New graduate nurse self-concept and retention: a longitudinal study. International journal of nursing studies, 46, 59-70 doi: 10.1016/j.inurstu.2005.03.004. Duchscher, J. B. (2008). Transition shock: The initial stage of role adaptation for newly graduated Registered Nurses. Journal of Advanced Nursing, 65(5), 1-11. doi: 10.1111/j.13652648.2008.04898.x Halfer, D. & Graf, E. (2006). Graduate nurse perceptions of the work experience. Nursing economics, 24(3), 150-155.
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References Harwood, M. (2011). Transition shock: Hitting the ground running. Nuritinga, 10(10), 1-11. Retrieved from http://www.utas.edu.au/__data/assets/pdf_file/0007/156661/M_ Harwood.pdf Hodges, H. F., Keeley, A. C. & Troyan, P.J. (2008). Professional resilience in Baccalaureateprepared acute care nurses: First steps. Nursing Ethics, 14 (6), 716-740. Horsburgh, M. (1989). Graduate nurses adjustment to initial employment: Natural field work. Journal of Advanced Nursing, 14, 610-617. Kelly, B. (1998). Preserving moral integrity: A follow-up study with new graduate nurses. Journal of Advanced Nursing, 28, 1134-45. Kilstoff, K., & Rochester, S. F. (2004). Hitting the floor running: Transitional experiences of graduates previously trained as enrolled nurses. Australian Journal of Advanced Nursing, 22(I), 13-17. Morrow, S. (2009). New graduate transitions: leaving the nest, joining the flight. Journal of Nursing Management, 17, 278-287. Stacey, G. & Hardy, P. (2011). Challenging the shock of reality through digital storytelling. Nursing education in practice, 11, 159-164 doi:10.1016/j.nepr.2010.08.003. Thrall, T. H. (2007). Shock absorbers. Hospitals & Health Networks, 81(6), 60. Walker, W. (1998). The transition to registered nurse: The experience of a group of New Zealand graduates. Nursing Praxis in New Zealand, 13(2), 36-43.
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