There are foundational intersecting elements that feed into the new graduate nurse’s (NGN) initial experience in the workplace: (1) stability, (2) predictability, (3) familiarity, (4) consistency, and (5) success (Duchscher, 2012). When all is in order, these elements put us in the driver’s seat of our own experience.
Figure 16.7.1 Quality Workplace Factors for New Nursing Graduates
“Quality Workplace Factors for New Nursing Graduates” is © 2012 Judy Boychuk Duchscher. All rights reserved, used with permission.
Stability refers to how steady the circumstances and situation are for you during your transition experience; essentially, stability refers to that which is unlikely to change or deteriorate. Stability is a fundamental feature of homeostasis, which even from a purely bio-physiologic perspective is something all humans seek. When you think about optimizing stability remember to think personally as well as professionally. Try to consider work that provides you with clinical situations that are stable, in a context that doesn’t constantly change. For this reason, floating (or being on a team that goes from unit to unit on a daily basis) does not provide for stability of patient population. Further to this, contexts where a patient’s clinical presentation is highly dynamic, or whose level of illness is such that there is a near certain likelihood of instability or decompensation (i.e., emergency or critical care), are precarious for the NGNs growing knowledge base. The immature pattern recognition capacity of the new practitioner renders the NGNs response to this kind of clinical volatility challenging. Finally, if you feel like your home life is unstable (i.e., things feel chaotic or stressful at home), the stability of your workplace is even more important. The reverse is also true: a stable home life is critical if you lack stability in the workplace.
Predictability for NGNs relates to their ability to know: (1) WHAT they will do (e.g., What level of performance is expected of me now that I am a graduate nurse? What do I need to do in this role? Am I comfortable enough with those in charge to tell them when I am in over my head?); (2) WHERE they will do it (Where am I working? Am I going to the same workplace every shift or floating to multiple units? If I have to start as a casual employee, how can I get enough hours without exposing myself to too many unfamiliar workplaces?); (3) WHEN they will do it (Am I working 8-hour or 12-hour shifts? What is the rotation? When X happens [a code, a death, a distraught patient, a diagnosis of a sexually transmitted infection, a suicide in the community], how do I respond?); (4) WHO will they do it with (Who will I be working with? Who do I go to if I have questions? Who can fire me? Who can I trust?); and (5) HOW they will do it (What are the differences between what I did as a student and what is expected of me now as a graduate nurse? What will I do if I come up against something I have never done before? Are things done differently here relative to where I practised as a student?).
Familiarity speaks to the saying, “I’ve seen this before,” and perhaps even “…and I know what to do about it.” If you were privileged to be employed as a senior student or spend your final practicum (or capstone or consolidated learning experience) on the unit or in the practice context where you intend to work as a graduate nurse, the lack of familiarity may not contribute as much to your transition stress. Even knowing where to get what you need to do your work is a relief of transition stress (e.g., where the STD kits are in the clinic or where the special bags of N/S with 20meqK+/L are located on the unit).
Knowing who’s who in the practice area is very helpful. While many NGNs experience phenomenal collegiality with their senior counterparts, there are equal numbers who are quickly introduced to, or warned about, those individuals to avoid because they “eat their young.” A new workplace is a bit like a minefield—you obviously need to keep moving but no one tells you where the mines are planted (sometimes even they don’t know) and not all mines have obvious triggers that you can see before they explode. It is in the area of familiarity that nursing residency/internship programs(also sometimes called a graduate nurse program or a transition facilitation program) or less formal supernumerary staffing arrangements have significant impact on a transition experience. Supernumerary staffing means that you work with patients and your colleagues without being given an actual assignment. The advantage of this is that you can move around your new environment, taking advantage of various learning experiences, getting to know your colleagues and the patient demographic without the stress of predetermined workload expectations. Mentorship or preceptorship programs constitute another approach to familiarizing you with your roles and responsibilities as a new nurse. The concept of mentor usually encompasses a longer-term, more personally professional relationship between a novice and experienced nurse. Conversely, the role of preceptor is often associated with the transferring of skill knowledge and therefore is often used in the context of a pairing between a nursing student and a senior nursing guide. Having said that, preceptors can also be expert clinical nurses who are buddied with a new nurse for the purposes of teaching them about the roles, routines, and responsibilities related to their new workplace. Along those lines, it is thought that we can be assigned a preceptor, but that a mentor is someone we choose, as this relationship requires a more personal connection between mentor and mentee.
Consistency is the experience of being exposed to a similarly presenting event, situation, concept, or idea, which affords you a level of familiarity and predictability. From a purely logical perspective, consistency is defined as that which does not contain contradictions. Here are some of the inconsistencies to watch for as you enter professional practice:
- The practice environment is more often than not constructed to ensure efficiency and productivity over effectiveness and quality.
- Health care institutions must function within budgets that are influenced by many competing sociopolitical and economic factors. This means that there will often be tension between the ethics-based, value-driven motivations of health care providers and the fiscal and human resource limitations of the health care system.
- When you graduate from an educational program that encourages independent critical thinking, it is a bit disconcerting to find yourself relatively dependent on the experienced nurses around you. You may feel a sense that you should be independent—you think others are expecting you to perform independently and this is what you often expect of yourself. Confusion reigns when you quickly come to realize that so much of what you are doing and seeing is new. The inconsistency is between what you think people expect of you, what you expected of yourself as a student, and the recognition of your own limitations as a new practitioner.
When experiencing inconsistencies, remember to stay grounded in the fundamental objectives of a NGN:
- Gain a sense of the roles and responsibilities of a graduate nurse.
- Create a workload organizational system that works for you.
- Learn how to manage your time within a gradually increased workload complexity.
- Learn the routines of your workplace.
- See and experience a variety of “normal” and “abnormal” situations under controlled conditions.
- Debrief with a trusted experienced colleague, nursing educator, or mentor about clinical situations to gain a depth of understanding of clinical patterns and the relationships between those patterns and the judgements that arise out of them.
- Gain confidence in performing the fundamental skills required of a nurse in the setting where you work. (The skills of an expert nurse are not simply tasks, but a complex and layered portfolio of roles and responsibilities enacted in an infinitely varied set of sequences and combinations and under dynamic, fluid and often intense and risk-laden conditions.)
- Assess patients of increasing complexity at varying levels of stability.
- Learn how to work on a team—and learn about your team.
- Get to know the dynamics of your workplace. What is “nursing” to your colleagues and how is nursing valued within your institution and community?
- Pursue a balance between your personal life and professional life.
- Learn who you are (again) now that you are not consumed by studying and academic deadlines.
- Have fun again!
Essential Learning Activity 16.7.1
Watch the video “Duchscher’s New Graduate Nurse Transition Stages” (19:53) by Dr. Judy Boychuk Duchscher who discusses new graduate nurse transition stages. Refer also to the following Figures 16.7.2 and 16.7.3. More information on new graduate nurse transition can be found on the Nursing the Futurewebsite. Answer the following questions:
- Describe the stages of transition. What recommendations does Dr. Duchscher give for each stage?
- Where do the majority of new nurses usually find employment? Why?
- What is flow? Give an example of flow.
- What is the difference between accommodating and adjusting?
Figure 16.7.2 Transition Stages Model
“Transition Stages Model” is © 2007 Judy Boychuk Duchscher. All rights reserved, used with permission.
Figure 16.7.3 Transition Shock Model
Enlarge image: Dec10 Transition Shock Model
“Transition Shock Model” is © 2007 Judy Boychuk Duchscher. All rights reserved, used with permission.