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Strategies new graduate registered nurses require to care and
advocate for themselves: A literature Review
Abstract:
Background:
New graduate registered nurses are confronted with a complex, demanding and resource
constrained environment where gaining acceptance into the workplace culture may be
difficult. Existing evidence suggests that preparing undergraduate nursing students for this
reality can assist with adjustment.
Objectives:
To identify the strategies that new graduate registered nurses require to care and advocate
for themselves during their first year of practice.
Methods
A search of the literature published between 2001 and 2016 was undertaken. Individual
articles were synthesized narratively and the results entered to a summary table.
Results
A total of 274 articles were considered relevant to this narrative review. This paper
synthesized the narrative of 80 articles. Synthesis revealed 22 resilience factors and 33
issues. Eight strategies with potential to assist new graduate registered nurses to care and
advocate for themselves were identified. All of them socioemotional in nature.
Conclusions
This review of the literature provides a valuable resource that can be used to prepare nursing
students for the workplace culture during their first year as a registered nurse. Scenarios can
be developed for educational activities such as simulation, role play, discussion and self-
reflection. Further development through research is recommended.
Keywords: new graduate nurse; self-care; self-advocacy; transition to practice; novice;
coping strategies; self-efficacy; resilience; hardiness.
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Impact Statement
A comprehensive resource that educators can use to prepare nursing students for the
workplace.
Introduction
In Australia and many other western countries internationally, new graduate registered nurses
(NGRNs) are not considered to be work ready by employers and transition to professional
practice programs (TPPPs) are provided as a panacea. In contrast, Zamanzadeh (2014) noted
that some non-western countries focus on the resilience of the NGRN and any formal
transition support may extend to as little as 14 days. This observation creates the following
causality dilemma: Has the rise of TPPPs influenced the preparation of undergraduate nursing
students by lowering performance expectations of graduates or is it the lack of preparation
that has influenced the rise of TPPPs? Unfortunately the western paradigm relies on the latter
i.e. transition programs of health organizations address gaps in practice not serviced by the
university sector. This paradigm has the effect of making universities impassive in their
preparation of students for nursing practice. For example, one of the first challenges that
NGRNs have to encounter is shift work. How do universities explicitly prepare them for this
phenomenon? How do they prepare students for inter-professional practice and the practice
conflicts, politics and inevitable horizontal violence that occurs? These questions are not
often answered in curricula and nursing students are unaware that the reality of the health
care environment is one of limited support, extreme challenge and unpredictability (Boychuk
Duchscher 2012).
Limited support for NGRNs remains likely into the foreseeable future as overstretched
health care institutions struggle financially. Even though there were pre-existing (i.e. prior to
2007) concerns (Delaney 2003), the global financial crisis has contributed even further to the
decline of transition support. This has been reported throughout the OECD and world-wide
(Morgan and Astolfi 2014 )2014). As a result, the likelihood that promises, such as
preceptorships, not being realized are more likely (Healy & Howe, 2012). The following
quote provided by Wangensteen, Johansson and Nordstrom (2008) illustrates the European
Union experience.
We were supposed to have a supervisor – we were supposed to have guidance in groups
– it all looked so fine. But we haven’t had any of that (….) It was very disappointing.
(Wangensteen et al., 2008, p.1880)
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Many resilience strategies are advocated in the current literature (Benner, 1984; Duchscher,
2009; McAllister & Lowe, 2011; Schoessler & Waldo, 2006), however further research is
required to identify the explicit resilience strategies NGRNs might adopt to thrive throughout
their graduate year. McAllister and Lowe (2011, p.6) define resilience as ‘a process of
adapting to adversity that can be developed and learned’.
Being prepared for the reality of diminished support is critical to the NGRNs success
and preparation is essential in the form of practical strategies that enhance their
foreknowledge and skill to manage potential dilemmas. The aim of this review was to
identify the strategies from previous research that are most likely to assist NGRNs to
advocate and care for themselves.
Background
Despite many reports and recommendations to the contrary, the likelihood that NGRNs will
find themselves in a chaotic, dysfunctional or unsupportive work environment remains quite
high (Adlam, Dotchin & Hayward, 2009; Dyess & Sherman, 2009; Kelly & Ahern, 2009;
Romyn et al., 2009; Clark & Springer, 2012; Chandler, 2012; Berry et al., 2012; Feng & Tsai,
2012; Hart, Brennan & de Chesnay, 2012; Laschinger & Grau, 2012; Thomas, Bertram, &
Allen, 2012). The NGRN often experiences both physical and emotional exhaustion and is
also likely to experience anxiety, low self-esteem, despair and a sense of hopelessness when
trying to ‘fit in’ to the new health unit environment. Due to this stress, many leave nursing as
a career (Greenwood, 2000; Cubit, 2011; Halfer & Graf, 2006; Figueroa et al., 2013; Wu
2012). The most often reported reasons for NGRNs leaving their first position as a registered
nurse relate to:
• Stress associated with acuity of clients, unacceptable patient/nurse ratios, feeling
patient care was unsafe (Bowles & Candela, 2005)
• role stress and oppression (Duchscher, 2008; Duchscher & Myrick, 2008; Douglas,
2014; Kovner et al., 2007)
• lack of management support and too much responsibility (Morrow, 2009)
• shift work, overtime and night shift interference with family life (Morrow, 2009)
• senior staff not perceiving that support is needed (Parker, Plank, & Hegney, 2003)
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• promises such as preceptorship not eventuating, preceptorship being inadequate or the
preceptor unwilling or unprepared to be supportive (Clark & Springer, 2012; Delaney,
2003; Harrison- White & Simons, 2013; Parker et al., 2014).
The contribution of the health care environment to the transition of NGRNs has
received a great deal of attention as illustrated above. However, discussion with regard to the
contribution of the academic environment and best practice with regard to addressing reality
shock and self-care needs have been minimal. It is anticipated that by identifying the self-
care strategies adopted by successful NGRNs and exploring the issues which impact on the
capacity to successfully navigate their transition year, curricula can be developed to provide
the appropriate education and resources.
Method
A literature search was undertaken and key terms were used in an attempt to identify
reported self-care strategies or issues relevant to the NGRN. However, use of key terms alone
was unsuccessful and searching within the articles by reading of the text and identifying the
strategies and issues discussed was required. For example, in the study by Mooney (2007a)
the text supported the need for strategies to address reconciliation of mistakes, however the
title of the article ‘Professional socialization: the key to survival as a newly qualified nurse’
did not reflect this content. As such, forensic searching of the text within the articles was
necessary to identify the potential resilience strategies important NGRNs.
The inclusion/exclusion inclusion criteria was designed to maximise the possibility of
locating the self-care strategies required by NGRNs during professional socialization.
Inclusion criteria
Inclusion criteria focused on critical research that informs the challenges, self-care strategies
and issues of relevance to the NGRN during their transition year. International and local
articles that were written in English and reveal the experience of NGRNs in the acute care
environment were included. This broad criteria was adopted so that the key elements and
self-care strategies which contribute to empowerment of the NGRN could be identified.
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Exclusion criteria
Acuity of clients and feeling that patient care is unsafe has been reported as a significant role
stress (Bowles 2005; Duchscher 2008). As such articles were excluded if the targeted
population of NGRNs undergoing transition was not in an acute care environment. Also
excluded were instances where experience and further training was an organizational
requirement before the NGRN was eligible to commence the transition being researched.
Search strategy
An online literature search was completed between 2001 and 2016, in CINAHL, Ovid
Medline, Informit, Google Scholar, and Web of Knowledge using the search terms: new
graduate nurse, self-care, self-advocate, transition to practice, novice, coping strategies, self-
advocacy, self-efficacy, self-esteem, resilience, hardiness, and self-management.
Many combinations of search terms were used to ascertain possible relevance to NGRNs.
Articles containing original research were read and assessed with regard to strategies or
issues relevant to NGRNs. After forensic examination, many were found to contain strategies
that had been adopted or issues that needed to be addressed by the NGRN to care and
advocate for themselves. Findings were recorded on a Microsoft Excel spreadsheet for
analysis and categorization.
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As illustrated in figure 1 a total of 445 articles resulted from the initial search that met the
inclusion criteria of possible relevance to NGRNs. Once duplicates were removed 274
articles were screened in accordance with the inclusion criteria. Of these, 139 full text
manuscripts were selected for further screening. Of these 80 articles were found to contain
self-care strategies that had been adopted or issues that needed to be addressed by the NGRN.
Findings were recorded on a spreadsheet for analysis and categorization. This process
continued until no further new strategies or issues were found.
Each article was read in order to answer the question, ‘What self-care strategies or issues
within this manuscript are relevant to the NGRN?’ When self-care exemplars were identified
they were allocated to a purpose designed Microsoft Excel summary table.
In developing the strategies, the researcher was sensitive to the elements of reality shock that
presented. Strategies were categorized with a focus on the resilience factors and also the
issues identified as being significant for NGRNs. For example, it is acknowledged that
horizontal violence is an issue of socialization however it is considered to need special
attention because of prevalence and the negative effect it can have on performance. It is also
acknowledged that the nature of social and emotional skills and the manner in which they are
allocated is dependent significantly on the situated context and judgement of the researcher
(Blyth, Olson, & Walker 2015; Braun & Clark, 2006).
Results
Research that specifically targets the preparation of nursing students for the realities of
practice with a focus on resilience was relatively small (Zamanzadeh 2014). The title of
articles did not always reflect the content and reading of the text was required in order to
identify the self -care strategies.
Identified strategies included the need to: explore personal self-support, reflection and
interpretive style, address social intelligence and the need of the NGRN to fit into the
organizational culture; understand the nature of transition; minimize horizontal violence,
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recognize and regulate emotions; manage moral distress and foster moral courage; self-assess
progress and performance.
Details of these findings will now be discussed:
Strategies of Interpretive style, Reflection and Personal self-
support
65 articles out of 80 related the importance of interpretive style, reflection and personal self-
support. Stress is reported to negatively impact the quality of care provided by new graduate
registered nurses (Thiesen & Sandau 2013). Management of stress is more effective where
NGRNs have good psychological capital. Psychological capital is described by Boamah and
Laschinger (2015, p.267) as a “positive psychological state of development that comprises
confidence, optimism, hope and resilience.”
Psychological capital in the form of interpretive style is a significant factor in
determining personal self-support for the new graduate registered nurse. Interpretive style is
how a nurse imagines their own ability to perform. This occurs positively through seeing
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oneself as being effective with regard to professional skills and not imagining failure (Simoni
et al., 2004). ‘Interpretive style can empower, reduce job stress and contribute to job
satisfaction for that same RN’ (Simoni et al., 2004, p.223) with the outcomes being increased
self-efficacy and confidence.
Nursing students can learn to manage stress by reflecting on scenarios in which they
have the opportunity to choose from a number of interpretations, including both effective and
ineffective cognitions. These activities may enable them as NGRNs to reflect on their
habitual ways of perceiving stressful situations and provide empowerment (Simoni et al.,
2004; Caldwell & Grobbel 2013). In addition to reflection, guided imagery has been
advocated as model for refining the transition process with benefits such as empowerment,
achieving positive outcomes and practice proficiency (Boehm & Tse 2013).
Spirituality can also provide meaning and help with gaining a positive perspective and
source of renewal (McAllister & Lowe, 2011). Lazar (2010) undertook a study among female
Israeli nurses and found job satisfaction was linked strongly to the sacredness of life, altruism
and idealism aspects of spirituality. Deliberately redirecting the locus of concern from the self
to a focus on ‘connection’ with patients and families has the reported benefit of providing
positive rewards (Clendon & Walker, 2012, p.558). Overall satisfaction in the spiritual
domain was found to spill over positively into the work domain.
The demands of shift work often results in the NGRN feeling fatigued, overwhelmed
and dislocated from friends, family and societal norms. Students need to explore the
ministration of these concerns more explicitly prior to taking on the role of registered nurse
(Ashton 2015; McCalla-Graham & De Gagne 2015; Pennbrandt et al 2013). Similarly,
students need to learn the difficult task of prioritizing and managing their patient allocation, a
portion of which, may involve death, grief or trauma (Ratta 2016; Zeng Lee & Bloomer
2015; Brisely & Wood 2004; Thiesen & Sandau 2013).
Ultimately it is important that NGRNs recognise when help is required and take
control. An effective way to ameliorate the impact of critical incidents involving the above is
to offer or request a “debrief” if that service is provided (Shinners 2016; Brisley & Wood,
2004; Mellor & Greenhill, 2014). In absence of a debrief, then being aware of and accessing
the resources available such as the employee assistance program is vital (Shinners, Africa &
Hawkes 2016).
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Strategies of Social intelligence and fitting in
There were 49 articles of the 80 articles that included social intelligence and fitting in
as a concern for NGRNs. Walker and Campbell (2013) identify social intelligence as a
critical work readiness factor. In fact, Feng and Tsai (2012) assert that NGRNs found
‘learning how to solve the gap between knowing and practising was easier than learning how
to behave appropriately and to deal with people in the workplace’ (p.2068).
Social intelligence is the ability to inspire, influence, empathize and care for others
(Johns Hopkins University, School of Nursing ND) or as Karl Albrecht (2004, p. 1) put quite
simply 'social intelligence is the ability to get along well with others, and to get them to
cooperate with you.'
The relationships and networks which an individual has developed within an
organization are significant (Taylor, 2012). Those who have strong connections and support
within an organization are likely to have more success than those who do not (Taylor, 2012).
There is also the vital need that NGRNs have to ‘fit in’ to the clinical situation to which they
are allocated and the importance of being accepted by senior staff (Feng and Tsai 2012;
Malouf & West 2011). Minor indiscretions such as not observing meal break times, being late
for work or being disrespectful can present as major obstacles to the acceptance of a new
nurse on the ward.
There are also other significant concerns based around the perceived shame of not knowing,
which challenge the NGRNs sense of self and patient safety (Feng & Tsai, 2012; Hamilton,
2005). NGRNs reported that ‘not wanting to be regarded as stupid’ had a significant
influence on their help seeking behaviour or reporting of mistakes (Crigger & Meek 2007;
Malouf &West 2011; Pennbrandt et al.2013). The potential for the NGRN to jeopardize
patient safety by avoidance of shame was found to be significant, particularly at the
beginning of a new placement (Malouf & West, 2011). As a result, high risk patients are
particularly stressful to the NGRN owing to the possible consequences for the patient and
fear of retribution (Ratta 2016; Crigger & Meek 2007).
Findings of graduates' fear of other staff members and their reprimands along with
limited assessment capacity could potentially lead to delay in early medical
intervention for the deteriorating patient. (Purling & King 2012 p. 3461)
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Development of trust in others to assist is important for the NGRN and a recommended
mindset for NGRN’s is to feel comfortable with not knowing everything (Cooper, Taft &
Thelen 2005). This requires access to a network of support in the form of a skilled person or
mentor and knowledge of other supportive resources (Ethridge, 2007; Hodges et al., 2008;
McKenna & Newton, 2008; Nugent, 2008). Consequently, it is important to adopt a proactive
approach when going to a new clinical area, one which comprises the asking of questions by
the NGRN about salient aspects of the routine and the staff who will be supportive (Feng &
Tsai 2012; Malouf & West, 2011). Another strategy considered helpful for fostering
engagement and enlarging the network of support is to become actively involved in the health
service through committees or projects (Bowles & Candela, 2005).
The strategy of understanding the nature of transition
There were 17 articles of the 80 that focused on the nature of transition and the need for
NGRNs to be aware of the enormity of this change (Malouf & West, 2011). The experience
of transition shock is well documented (Duchscher, 2009; Boychuk Duchsher 2012) and
NGRNs need to understand the nature of this shock so that they can prepare emotionally,
physically, developmentally and intellectually (Duchscher, 2009; Malouf & West, 2011;
Romyn et al., 2009; Ashton 2015). This includes role conflict between long-established
hierarchical nursing traditions and what was learnt as an undergraduate (Kelly & Ahern,
2009). Learning about the nature of transition within the syllabus as an undergraduate nursing
student may empower the NGRN. ‘Transition’ in the context of ‘transition to practice’
encompasses giving up being a student and taking on the whole new world of being an
employee and a registered nurse with all that it entails (Benner, 1984; Boychuk Duchscher,
2012; Duchscher, 2008; Schoessler & Waldo, 2006). Each transition model has distinct
developmental phases which highlight that the NGRN is a work in progress and not a
finished product. NGRNs are reported to benefit from understanding this continuum so that
they can contextualize the difficulties they may have when comparing themselves with expert
or more experienced nurses (Burger et al., 2010; Hartigan et al., 2010).
Strategies to minimize Horizontal violence
15 articles of the 80 articles dealt explicitly with horizontal violence and the NGRN.
However, fear of retribution, avoidance behaviors, poor relationships with preceptors and
complaints of unsupportive staff featured in many other articles.
Horizontal violence and harassment in its many forms are often experienced by the
NGRN (Kovner et al., 2007; Kramer et al., 2012; Laschinger & Grau, 2012; Morrow, 2008).
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In fact, Laschinger and Grau (2012) found that one third of NGRNs experienced workplace
bullying, with those under the age of 30 years experiencing bullying for a longer period than
their older counterparts (Clendon & Walker 2012). Sexual harassment was also reported as
more common among younger NGRNs of both genders (McKenna et al., 2003). Surprisingly,
Berry et al. (2012) related that often ‘the experienced nurses expected to mentor and provide
support to NNs [Novice Nurses] are the primary perpetrators of WPB [Work place bullying]’.
Other perpetrators were staff nurses (44%) and nurses in leadership positions (19%) with
physicians accounting for only 6% of reported bullying (Berry et al., 2012). Feng and Tsai
(2012) also found physicians were much less problematic regarding bullying behaviour than
were senior nurses. This is significant as NGRNs often feared talking to physicians because
of reported stories of abuse (Hodges et al., 2008; Thomas et al., 2012). Effective
communication between clinicians, other staff and students was identified as a strategy to
decrease horizontal violence (Curtis, Bowen & Reid, 2007). ISBAR (Finnigan, 2010) - a
well-recognised formalised handover communication tool incorporating Identification,
Situation, Background, Assessment and Recommendations - was found empowering to the
NGRN in the context of providing a predictable means of communication between health
professionals (Goodwin-Esola, Deeley & Powell 2009).
Berry et al. (2012, p.84) found significant correlation between work place bullying and
negative work productivity of novice nurses. Development of psychological capital is
considered both a personal resource and protective factor against adverse outcomes for
patients (Laschinger & Grau 2012):
Psychological capital, a personal resource, influenced new graduates’ sense of fit
between their job expectations and their actual working conditions, which in turn
influenced the extent to which they reported experiencing bullying in the work place
(p.289).
Providing nursing students with skills to address the issue of bullying in the workplace may
help them see their experiences more objectively and reduce the likelihood that bullying is
perpetuated by successive generations of NGRNs (Berry et al., 2012; Curtis et al., 2007;
Laschinger & Grau, 2012; Pines et al., 2012).
Strategies of Recognizing and regulating of emotions
There were 12 articles of the 80 articles that included recognizing and regulating of emotions
as a concern for NGRNs. Essentially, emotional intelligence is about self-regulation and
mastery of emotions (Zito 2012). In particular, Freshwater and Stickley (2004) assert that
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emotional intelligence should be integrated throughout the nursing curriculum to facilitate the
essential leadership skills in learning to care for one-self and others. Emotional intelligence
competency requires self-awareness. This includes knowing one’s own strengths and
limitations, being mindful of feelings in the moment, and knowing how feelings can affect
decision-making and other people (Yale Centre for Emotional Intelligence 2013; Rochester et
al., 2005). Emotional intelligence is defined as:
A type of social intelligence that involves the ability to monitor one’s own and others’
emotions, to discriminate among them, and to use the information to guide one’s
thinking and actions. (Mayer & Salovey, 1993, as cited in Johns Hopkins University,
School of Nursing. n.d., p.1)
To illustrate the potential value of emotional intelligence, a study was undertaken by
Rochester et al. (2005) with regard to the capabilities of 17 NGRNs rated by their supervisors
as successful. It was noted that during stressful situations the successful graduates
demonstrated more highly developed emotional intelligence and clarity of thinking
(Rochester et al., 2005).
A number of other articles also considered emotional intelligence essential for
effective leadership and nursing performance (Beauvais, Brady, O’Shea & Griffin 2011;
Freshwater & Stickley, 2004; Kooker et al., 2007). This includes providing students with the
skills to relate inter-professionally at all levels so they have equitable influence on patient
care planning and advocacy (Bulmer-Smith, Profetto-McGrath, & Cummings, 2009; Shanta
& Connelly 2013; Pfaff et al. 2014). These skills for dealing with emotional information need
to be developed in nursing students through education and support (Bennett & Sawatsky
2013; Towell, Nel & Muller 2015; Rochester et al., 2005).
Strategies to manage moral distress and foster Moral Courage
There were 10 articles of the 80 articles which focused on moral distress and moral
courage as a concern for NGRNs. McAllister and Lowe (2011) highlighted the importance of
learning to manage moral distress, particularly where there is conflict between insufficient
time for care and being true to one’s own values and those learned. This can result in stress,
conflict of conscience and an impoverished sense of self:
They were extremely hard on themselves when they felt they had failed to identify or
appropriately intervene in a changing clinical situation. Despite the fact that many of
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the situations in which they were placed were beyond their intellectual or physical
capability, their behaviour was consistently self-deprecating. (Duchscher, 2008, p.445)
In addition, the self-expectations of NGRNs are often distorted by their beliefs about their
ability to handle moral distress issues in practice (Juthberg et al., 2007). Schluter et al. (2008,
p.306) describes moral distress as:
An emotion that is expressed when the moral complexity of a situation is not leading to
a resolution, thereby having the potential to cause harm to the individual nurse […]
painful feelings and associated mental anguish as a result of being conscious of a
morally appropriate action, which, despite every effort, cannot be performed owing to
organizational or other constraints.
Cooper et al. (2005) discuss how third-year students had forethought and anxiety about
the roles they would perform in their graduate year. ‘Several students discovered errors either
made by others or themselves during their clinical experience. This raised significant fears
about their responsibilities as an RN’ (Cooper et al., 2005, p.296). This level of responsibility
and accountability cannot easily be tested as an undergraduate (Hickey, 2009; Zheng, Lee &
Bloomer 2015). However, it is possible for students to be given the opportunity to explore the
relationship between moral distress and moral courage in the context of future practice. In
actuality, moral courage in practice is considered an effective response to moral distress
(LaSala & Bjarnason, 2010).
Strategies to assess progress and performance
7 out of 80 articles provided information with regard to the reluctance of staff to assess and
provide formal feedback on NGRN’s progress and performance. Developmental and positive
feedback has been reported as helpful for providing a feeling of developing competence over
the course of the graduate year (Hamilton, 2005; Parker et al., 2014; Wangensteen et al.,
2008). NGRNs preparing for their first year in practice and in the early stages are eager to
receive feedback on their progress (Mellor & Greenhill, 2014; Wangensteen et al., 2008). Yet
articles from Europe and Australia have demonstrated that more experienced nurses are
reluctant to provide effective feedback (Wangensteen et al., 2008; Parker et al 2014). The
opportunity to reflect on practice and view challenges as learning experiences is purported to
assist with resilience and the development of a positive perspective (Wangensteen et al.,
2008). In particular, Generation Y individuals born between 1981-1994, who represent a
large proportion of current NGRNs, desire quick and continuous feedback (Keepnews,
Brewer, Kovner & Shin, 2010; Lampe, 2011).
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Although many of the participants (new graduate registered nurses in a graduate nurse
program) felt strongly about their own responsibility and need to pursue help if
necessary and not to be reluctant or deterred by lack of interest by their senior
colleagues, they reported they would have benefited from constructive feedback about
their performance. Often the only feedback they received was based on the fact that no-
one was complaining or no major mistakes had been made. They would have preferred
some encouragement and genuine interest in their performance. It would have helped
with their confidence and reduced the stress they experienced from not knowing how
others perceived their performance. (Parker et al. 2014, p. 154)
Due to the importance of receiving feedback on performance, it has been suggested that,
in the absence of formal feedback, nursing students should be prepared to find options and be
proactive in this regard. Assertively seeking progress meetings can be a resilience strategy for
the NGRN in order to reaffirm progress, instil a sense of achievement, explore learning
opportunities and set new goals (Goodwin-Esola et al., 2009).
If attempts to gain feedback are not successful, there are alternative or complementary
options, such as maintaining a portfolio, reflective journal or being alert for other measures of
success (Sewell, 2008). These measures may include feedback from patients, being given
extra responsibility or informal feedback on practice during the course of the shift etc. Those
who have had experience with a reflective journal find that writing assists with self-
assessment of progress, provision of perspective and a sense of achievement (Day & Rickard,
2012). Additionally, the use of social media and web blogs as a critical event journal has been
suggested for debriefing and shared learning (Sewell, 2008).
Discussion
There is reported to be little research on how to manage specific stressors associated
with reality shock (Thiessen 2016). The objective of this literature review was to identify
research that has a focus on the strategies NGRNs employ to manage these stressors. It is also
acknowledged that every student will have a different capacity for resilience. At the outset,
nursing may have been a default option and not the students preferred profession or perhaps
nursing was a stepping stone to another career. As a consequence, this background can
negatively influence an individual’s vulnerability, engagement, perception and occupational
health (Rudman & Gustavson 2012). Conversely, undergraduate nursing students may
15
already have well developed resilience prior to commencement of their studies in nursing
(Rudman & Gustavson 2012). In a study by Chamberlain et al. (2016 p.8) it was found that
‘the strongest predictors of resilience (in nursing students) were attributed to dispositional
mindfulness and its subset of acceptance’.
A major challenge to personal resilience relates to the nursing and hospital culture.
While professional socialization promises to ease transition when effectively scaffolded, such
a network can also be a threat, because of the stress of enculturation to ritualistic practices
and expectations (Boychuk Duchscher 2008). Inevitably loss of empowerment and moral
distress is a likely result if pressured in this way to compromise care (Mooney 2007b;
Hamilton 2005; Boychuck Duchscher 2004).
In response to these concerns, this study has garnered evidence based strategies
reported to assist with facilitating the safe transition of NGRNs and improve their willingness
to remain in the workforce. Bridging the gap between the undergraduate experience and the
clinical world of nursing is essential to reduce reality shock i.e. ‘a more accurate academic
acknowledgement of the clinical world of nursing may decrease new graduates’ sense of
anxiety inherent within the professional nursing role’ (Winfred, Melo & Myrick 2009 p. 12).
Hamilton (2005, p.76) describes these disconnects as:
Discursive dissonances or differing constructions of the new graduate within
institutional discourses of education and health service. In educational discourse the
graduate is positioned as a critical thinking and knowing care giver . . . health
service discourses work to construct new graduates as functional, efficient,
organizational operatives providing a nursing service.
In accordance with this foreseeable assault on the NGRNs sense of self as a professional,
evidence suggests that a nurse’s self-concept fluctuates at the developmental stage as they
make the journey from student to graduate nurse (Pfaff 2014). As a consequence, there are
implications for safe patient care and strategies should be directed towards enhancing the
undergraduate nurse’s self-confidence in preparation for transition (Cowin et al. 2006 p. 30).
NGRNs who lack confidence are less likely to assert themselves in an inter-professional
context, are fearful, easily intimidated, and patients may suffer as a result (Pfaff 2014).
Confronting the realities of practice in the classroom will be of benefit to nursing
students before they become NGRNs (Shinners 2016; Theisen 2016). Students will likely
have misgivings from their engagement with the clinical practice environment as they may
have already experienced horizontal violence and pressures from a variety of sources
16
(Hamilton 2005). Hence, students should be eager to participate in conversations of this
nature, to share their stories and learn from each other. Possible conversations include:
• The issues surrounding medication errors and reconciliation of mistakes, particularly
when students may have witnessed the mistakes of others (Cooper et al. 2015).
• The confounding problem of moral distress when as students they may have been
attempting to perform best practice and are discouraged from doing so (LaSala &
Bjarnason, 2010).
• The need to self-assess their own progress as in some work place environments it is
unlikely that such an opportunity will be provided to them on a regular basis (Parker
et al., 2014).
• The potential for the NGRN to jeopardize patient safety due to avoidance of shame as
was found by Malouf and West (2011).
Overall, there is a need to acknowledge the complexity of the nursing and health care culture
in a neutral classroom environment. Firstly, learning that their shared experiences are similar
is likely to be beneficial for students and secondly, provision of the opportunity to discuss
possible responses and rehearse solutions can be therapeutic and empowering (Goleman &
Boyatzis 2007; Shinners, Africa & Hawkes 2016). As a consequence of this repositioning,
students would be afforded an extra layer of resilience so that, when they adopt the role of
NGRN, they recognize their struggles, not as a failure on their behalf, but a product of the
many challenges of the culture of nursing and health care environment.
Strengths and Limitations
The inclusion of a large number of journal articles in this review may be considered a
strength. All manuscripts were from peer reviewed journals. During thematic analysis, some
themes were well supported by a large number of references while others have less support
due to the paucity of research in that area. This does not mean that a theme should be
discounted (Braun & Clarke, 2006) with regard to recommended strategies or issues of
concern for the NGRN. For example, there was a relatively small number of references
representing the theme ‘strategies to manage moral distress and foster moral courage’.
However, this theme was compelling, considered relevant and therefore retained.
17
Conclusion
This study was a first step toward development of a comprehensive approach to
undergraduate education that prepares nursing students for transition to practice. Strategies
recommended include the need to: explore personal self-support, reflection and interpretive
style; address social intelligence and the need of the NGRN to fit into the organizational
culture; understand the nature of transition to practice; minimize horizontal violence;
recognize and regulate emotions; manage moral distress and foster moral courage; self-assess
progress and performance. Enacting any one of these strategies in professional practice is
purported to be a significant determinant of “well-being” outcomes for both the patient and
NGRN. Interaction of two or more strategies would be even more empowering. Further
research is recommended to determine the most effective ways to teach these strategies, to
verify their effectiveness and identify possible further inclusions that will improve the
capacity of NGRNs to be successful during transition.
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