Nurse Practice Reflection Worksheet – Distractions & Reduction of Risk Potential NAME Read/watch the assigned material and then respond to the questions below based upon what you learned in class and in the articles/videos you watched. Descriptions and discussions require a minimum of 8 detailed, high-quality, senior-level written sentences. It must be evident in each question that states specific articles or videos that the entire article was read or video was watched. 1. - Describe a situation that has happened to you, or that you have witnessed during your time nursing school (work or clinical), in which distraction interfered with the nurse’s ability to provide safe, quality, patient care. Include details of the situation, who (no names, just include experience level, etc. only), what, where, when, why, and how of the situation. (10 sentences) - Using what was learned in class and from the assigned readings, discuss what preceded the distraction or why the distraction was allowed to happen. (For example, is this the usual culture on the unit? If so, why is it tolerated?) (10 sentences) - How could the nurse manage interruptions or distractions better next time? (3 sentences) - State one specific example about effective distraction management techniques learned in class or one learned from any of the assigned readings. (3 sentences) - Discuss four of the various transition strategies presented in the assigned reading. (10 sentences) What does the evidence show are successful transition strategies? (5 sentences) 2. 3. Read and discuss the parts of the research article, Faculty’s Role in Assisting New Graduate Nurses’ Adjustment to Practice, by Lisa Sparacino, PhD. Abstract/Background/Literature: - What did you learn in this section? (5 sentences) What theoretical frameworks support the research? (5 sentences) Methods: What is the purpose of the study? (5 sentences) Methods: Discuss the research design. (10 sentences) Discussion & Conclusion: Discuss the key Faculty attributes that contribute to students’ view of Faculty as mentors and educators aiding in successful transition. (10 sentences) 4. - Discuss your thoughts about the article, Should Nurses Blow the Whistle or Just Keep Quiet? by Carolyn Buppert, MSN, JD. (10 sentences) What is important about it? (3 sentences) What is your key take-away? (3 sentences) How does it relate to nursing culture, the ANA Code of Ethics, and morality? (3 sentences) International Journal of Nursing December2015, Vol. 2, No. 2, pp. 37-46 ISSN 2373-7662 (Print) 2373-7670 (Online) Copyright © The Author(s). 2015. All Rights Reserved. Published by American Research Institute for Policy Development DOI: 10.15640/ijn.v2n2a5 URL: http://dx.doi.org/DOI: 10.15640/ijn.v2n2a5 Faculty’s Role in Assisting New Graduate Nurses’ Adjustment to Practice Lisa L. Sparacino, Ph.D., RN, CCRN, CNE1 Abstract The gap between the role of the nursing student and that of the practicing registered nurse is well known. Kramer (1974) used the term “reality shock” to explain the anxiety, doubt, and confusion nurses experience as they advance from the role of nursing student to professional registered nurse (p. 9). Reality shock, also called role transition, leads as many as 30% of new nurses to leave the profession or change jobs within their first year of employment (Duchscher, 2009). While studies show how the health care industry addresses the problem of reality shock (Bowles & Candela, 2005; Duteau, 2012; Dyess& Sherman, 2009) and the successful preparation of students’ entry into nursing in terms of student achievement (Benner et al., 2010; Billings & Halstead, 2012), neither approach thoroughly explores the role of nursing faculty from the perspective of the student preparing for the professional role (Benner et al., 2010). Institutions of higher education have been called upon to better equip graduates with the tools necessary to compete in the workforce (Cornish, 2004). Nursingeducators recognize they havean ethical and professional obligation to prepare students to enter practice ready to master the skills needed to ensure safe, high-quality patient care (Benner et al., 2010). Nursing faculty recognize the need to provide an educational experience and positive learning environment for all students, resulting in educators continually introducing multiple teaching, learning, and assessment techniques to support students’learning successes (Billings & Halstead, 2012). Teaching technique evaluations determine whether a methodology improves cognitive and psychomotor learning (Benner, 2010; Billings & Halstead, 2012), but more information is needed to determine what effect multiple teaching methodologies have on promoting new nurses’ clinical competence and confidence. This research study examines the impact of nursing faculty on role transition from the perspective of newly graduated registered professional nurses. For purposes of this study, newly graduated nurses are defined as having less than 3 years of experience.Understanding which nursing faculty behaviors promote a smooth transition from the role of student to that of professional practicemay inform nursing faculty of the impact of their behavior on new graduate nurses and encourage more new nurses to remain in the profession. Background/Literature The ability of the new graduate nurse to adapt to the role of professional registered nurse has been examined repeatedly since Kramer (1974) introduced the concept. Early studies intent on improving orientation programsexamined how role transition affects attrition rates (Schempp&Rompre, 1986), with studies on role transition changing as needs of the health care industry evolved. For example,Myrick (1988) studied the implementation of preceptorships, and others examined preparedness of new graduate nurses by scrutinizing the educational process and developing educational standards (American Association of Colleges of Nurses [AACN], n.d.; Benner et al., 2010; National League for Nursing [NLN], n.d.). 1Assistant Professor, Simulation Coordinator, Department of Nursing, New York Institute of Technology, Northern Boulevard, Building 500, 506 D, Old Westbury, NY 11568-8000, lsparaci@nyit.edu, phone: 516-650-7456, fax: 516-686-3781 38 International Journal of Nursing, Vol. 2(2), December 2015 Three theoretical frameworks support the assumptions of the researcher. First, the framework of Kramer’s (1974) reality shock is used to outline the significance of the problem. Benner’s (2001) novice-to-expert theory provides a foundation for understanding the cause and effect of role transition and the new graduate nurse. The theoretical framework for this study is further expanded through Roy and Andrews’s (1991) theory of adaptation, supporting the importance and purpose of the study. Kramer (1974) asserted that reality shock occurs in nursing because the level of commitment is viewed as permanent, and literature continues to report on reality shock for all new graduate nurses (Martin & Wilson, 2011). New graduates must develop organizational skills to function effectively, productively, and indefinitely (Kramer, 1974). Student-based cognitive and psychomotor skills are tested as new nurses strive to acquire nursing skills and adapt to organizational expectations. The complex process of transition involves more than knowledge, technical skills, and abilities. Reality shock shares basic concepts with culture shock. Culture shock (Oberg, 1960) is the phenomenon experienced by Western society travelers who venture to Third World countries and vice versa. Differences of language, customs, and social norms burden newcomers, leaving them feeling alienated. Successful acclimation always results in the person accepting and enjoying the attributes of the new culture (Oberg, 1960). Kramer’s (1974) outline of reality shockincludes the phase’s ofhoneymoon, shock, recovery, and finality.New graduates in the honeymoon phase are excited about embarking on a new career. They enter the workplace with euphoriaand an idealistic understanding of their professional role. The euphoria is short-lived andthe honeymoon phase ends abruptly; new graduates no longer recognize the familiar signals of school. Shock and rejection set in, and new graduates become anxious, angry, and confused (Kramer, 1974). Equivalent with the negotiation or disintegration stage of culture shock, the shock phase results from inconsistencies between what was previously perceived as normal and what is now being presented as normal in the new surroundings (Kramer, 1974; Oberg, 1960). During the shock phase, the most extreme responses are seen, resulting in medical errors, multiple job changes, and/or abandoning the profession of nursing (Duchscher, 2009; Morrow, 2009; National Council of State Boards of Nursing [NCSBN], 2011). New graduatesequipped with the tools to successfully navigate through the shock phase progress to the recovery and final phase, evolving from an advanced beginner to a competent practitioner (Benner, 2001). Benner’s (2001) novice-to-expert theory, first published in 1982, embodies the concept of nurses developing professional expertise over time. This theory describes performance characteristics and learning needs of the professional nurse during various stages of clinical practice.A person acquires or perfects skills through trial and error, or by seeking professional instruction (Dreyfus & Dreyfus, 2000). Skill acquisition is a process consisting of five developmental stages: novice, competence, proficiency, expertise, and mastery (Dreyfus & Dreyfus, 2000).The novice has little or no experience (Benner, 2001).Generally, novices are nursing students. Nursing studentsare inflexible;their behavior is limited to theory and rules. The new graduate is considered an advanced beginner (Benner, 2001). Clinical experience learned in school is the knowledge base that guides care (Martin & Wilson, 2011), but the advanced beginner lacks the skills to effectively identify patient needs and prioritize care (Benner, 2001). The competent nurse has developed the ability to plan and organize efficiently; his or her actions are viewed in the context of developing long-term goals, both patient-centered and professional. As the nurse remains in practice, proficiency and expertise are achieved. The proficient nurse can visualize situations as a whole and easily recognize deviations from the norm (Benner, 2001). The expert requires no expenditure of energy to understand a situation; decisions are made quickly, without the need for considering rules or alternative solutions (Benner, 2001; Dreyfus & Dreyfus, 2000). Skills acquisition occurs secondary to experience. Experience is not defined by time; it is a process of reflection and reconstruction of preconceived assumptions amid real-life situations (Benner, 2001). A nurse progresses from novicetoexpert as mastery is achieved in each practice domain. In other words, a nurse in the early stages of skills acquisition relies on strict adherence to rules; he or she cannot transform the characteristics of the domains of practice and apply them (Gentile, 2012). The domains of nursing practice are the helping role, the teaching-coaching function, the diagnostic and patient-monitoring function, effective management of rapidly changing situations, administering and monitoring therapeutic interventions and regimens, monitoring and ensuring the quality of health care practices, and organizational and work-role competencies.The expert nurse uses reflection to synthesize multiple experiences, allowing for a nonlinear, holistic response (Benner, 2001; Gentile, 2012). To achieve expertise in practice, the nurse must master each earlier stage (Benner, 1991; Dreyfus & Dreyfus, 2000). Progression through the levels of expertise has implications for education and professional development. Lisa L. Sparacino 39 Transforming from novice to expertallows the new graduate nurse to be viewed as an adaptive system (Roy, 1988). As an adaptive system, the new nurse experiences multiple stimuli, adjusts behavior accordingly, and produces responses that effect changes in the environment (Roy & Andrews, 1991).Stimuli-triggered behavior is either adaptive or ineffective. An ineffective response hinders the nurse from growing in a situation. A single ineffective response usually is not problematic,but repeated and ongoing ineffective responses prevent adaptation (Roy & Andrews, 1991). Failure to adapt is exemplified by the new graduate who has difficulty progressing through reality shock and cannot progress from advanced beginner to competent practitioner.High attrition rates and increasing costs of new graduate orientation are consistent with ineffective responses in nursing (Pinchera, 2012). Many studies suggest unpreparedness contributes to the high rate of care errors by new nurse graduates (Benner et al., 2010; Culleiton, 2010; Saintsing et al., 2011). Ineffective responses such as errors foster feelings of inadequacy and frustration, undermining professional relationships and successful professional development (Pinchera, 2012). Understanding the obstacles new graduate nurses encounter may allow for the creation of stimuli promoting adaptive responses, thereby avoiding disequilibrium of the personal self (Roy & Andrews, 1991) and support an easier transition through the phases of reality shock. Despite ongoing improvements in nursing education, 21st-century nurses enter the complex health care environmentwithout the skills and knowledge needed to practice (Benner et al., 2010). An estimated 25% of new graduate nurses lack critical reasoning and problem-solving skills, leaving them unable to provide safe patient care (Fero et al., 2008; Saintsing et al., 2011). These nurses lack the capacity to maintain and enhance the knowledge base for continued safe, high-quality patient care (Benner et al., 2010). Education, experience, and personal factors such as parental relationships, general career expectations, and economics all play a role in the new graduate’s ability to acclimate to professional practice (Farner& Brown, 2008). Feelings of helplessness and anxiety have an impact on the new graduate’s progression into practice and undermine professional development (Pinchera, 2012). Continuing research may improve educational methods to ensure new graduate nurses enter professional practice prepared to meet healthcare industry demands (Benner, 2001). Various orientation programs and residency programs are been proven to benefit the socialization process (Berkow et al., 2008). Lampe et al. (2011) noted orientation programs that meet new graduates’ specific needs are more likely to empower, but orientation program effectiveness depends on new graduates’ knowledge base upon entering the program (Benner et al., 2010). Reducing reality shock and improving empowerment are linked to improved retention and professional satisfaction. Industry educators and nursing faculty recognize the need to reevaluate the nursing curriculum and minimize the turbulent transition from student nurse to professional registered nurse (Benner et al., 2010; Greene, 2010). Members of the current healthcare industry expect nursing faculty to educate students who are ready for the challenges of professional practice (Roberts et al., 2009). 2. Methods Purpose of the Study This study seeks to understand nursing faculty behaviors that effect new graduate nurses’ ability to successfully move from the role of student to that of professional registered nurse. Kramer’s (1974) initial investigation into role transition revealed multiple challenges because the new graduate nurse to experience reality shock. Role transition and challenges encountered in nursing because of role transition are complex and multifaceted. One aspect of role transition that remains incompletely understood is the interactionism between nursing faculty and nursing student and its part in successful role transition. Human behavior is complex and complicated. Investigation of human behavior honoring an inductive style lends itself to qualitative methodology (Creswell, 2014). Appreciating social interactionism—human behavior predicated on social interactions—requires active participants who can create meaning and provide data reflective of specific behavior (Morse & Field, 1995). The purpose of this research was to develop a beginning theory for nursing faculty to use as a framework to enhance nursing education. This theory is intended to provide nursing faculty with an outline of behaviors, actions, and teaching methodologies best suited to assist students to adjust to the role of professional registered nurse. 40 International Journal of Nursing, Vol. 2(2), December 2015 The opinions of new registered nurses who successfully adjusted to professional practice were solicited. Study participants’ ability to correlate their experiences as students to their success in adjusting to professional practice was key to development of the beginning theory. This population was assumed to be best able to provide data because these new graduate nurses succeeded in transitioning from the role of student nurse to professional registered nurse. Purposeful sampling of a targeted population was applied. Study participants needed to be able to accurately recall and discuss nursing school experiences that affected their ability to adjust to professional practice. Participants met the following criteria:       Graduated from a pre-licensure accredited nursing program within the last 3 years, Passed the NCLEX-RN on the first attempt, Were employed by the same institution for at least 1 consecutive year, Had not engaged in nursing as a second career, Had not been previously employed as a nursing assistant or patient care administrator, and Orientation did not include participation in a formal nurse residency program. Research Question Data collection and analysis in grounded theory is indirect and varying (Glaser, 1998). There remains a need to explore the teaching, learning, and assessment methods that best prepare future nurses for professional practice. The purpose of the study, to identify behaviors used by nursing faculty that, according to new nurse graduates, increased new graduate nurses’ ability to enter the profession optimally prepared for the challenges and equipped with the greatest confidence, knowledge, and communication skills possible, guided development of the research question: What nursing faculty behaviors, encountered when new graduate nurses were students, most influenced new nurses’ ability to adjust to the role of registered professional nurse as a competent clinical practitioner? The following guiding questions posed during the interviews assisted the researcher in answering the research question, although the participants’statements guided the interview. 1. Tell me about your interactions with nursing faculty while in nursing school that helped you develop as a professional practitioner. 2. As you look back to when you were a student nurse, what teaching strategies did nursing faculty use that have helped you adjust to being a registered nurse? 3. As you look back to when you were a student nurse, what actions displayed by nursing faculty do you believe have helped you become a confident professional? 4. What do you think were the most important actions and behaviors exhibited by nursing faculty when you were a student nurse that have helped you deal with the demands of the nursing profession? 5. Can you tell me anything else about your interactions with nursing faculty as a student nurse that have influenced you as a professional nurse? 6. Can you think of any act or behavior you encountered in your interactions with nursing faculty that inhibited your ability to successfully adjust to the role of professional nurse? Research Design Grounded theory was used to define the basic social process behind reality shock and develop a beginning theory grounded in the data (Glaser & Strauss, 1967) to answer the research question. Grounded theory methodological rigor provided structures for development of thebeginning theory, allowing the theoryto remain grounded in data and truthful to the study purpose. In grounded theory, sample size is guided by the data. Data were collected until a complete understanding of the topic was achieved (Charmaz, 2006). An Ohio Board of Nursing listserv was used to contact potential participants who satisfied the inclusion and exclusion criteria (Table 1). Potential participants were mailed a request for further contact form containing the inclusion criteria. Of the 700 requests for further contact sent, 24 were returned. Lisa L. Sparacino 41 Table 1: Inclusion and Exclusion Criteria Inclusion criteria Graduated within the last 3 years Passed NCLEX-RN on first attempt Consistent employment at same institution for a minimum of the past year Nursing is the first career Never worked in a job requiring patient care Did not participate in a formal residency program Exclusion criteria Graduated more than 3 years prior Passed NCLEX-RN after multiple attempts Employed by multiple institutions within the past year Previous career(s) held Previously engaged in patient care Participation in a formal residency program Potential participants were contacted using the information provided by the Ohio State Board of Nursing. Twenty participants were successfully recruited for interviews. Data saturation was achieved after 13 participants were interviewed. Data coding provided the framework for generating theory quintessential to the reality it embodies (Strauss & Corbin, 1990). Coding to generate theory followed a process of constant comparison (Glaser & Strauss, 1967) using open coding, followed by axial coding, followed by selective coding. Open coding was performed as each interview tape was transcribed; exposing initial concepts and meanings that guided further data collection (Corbin & Strauss, 2008). As data emerged, concepts were identified, analyzed, compared, and categorized. Focused or axial coding was conducted next. Axial coding asks “when, where, why, who, how, and with what consequences” (Strauss & Corbin, 1998, p. 125). The coding process concluded with selective coding. Selecting coding involves creating a case study or story derived from the data (Strauss & Corbin, 1998). Creating a case study places the collected data into context, providing the framework for the beginning theory development. Thirteen participants provided individual points of view regarding nursing faculty behaviors. Telephone interviews were analyzed and coded using grounded theory. Constant comparison of data using multiple methods of coding supported an unremitting relationship between data collection and analysis, thereby sustaining validity of the grounded theory methodology (Bryant, 2009; Glaser, 2003; Glaser & Strauss, 1967). As data representing each participant’s point of view were analyzed using open coding, axial coding, and selective coding, common concepts, themes, and categories became apparent. The final categories that emerged are caring, rigor, experience, knowledge, and professionalism. Data/Results/Findings Participants correlated their memories of student experiences with the ability to handle obstacles as they launched their professional career. The central themewas caring, identified through several stories. Examples included how appreciative participants were of nursing faculty who took extra time to review or explain content. Participant 5 remarked, “I always went to one professor when I didn’t understand something. . . . [She taught] me how to look up what I didn’t know. .. . Being able to gather information quickly helped me in the beginning.” Participants related nursing faculty’s ability to demonstrate caring with the ability to learn, apply knowledge, and reflect fairly on their own performance. Each participant mentioned program rigor, correlating adherence to a rigorous program with his or her ability to manage stressful situations at work. One participant said, “[M]y manager complemented . . . my professional attitude. . . . [M]y professors . . . enforc[ed]. . . policies. . . . [C]oworkers. . . treat me with [more] professionalism . . . ” The most common sentiment referred to the ability to adapt to social nuances. Several participants referenced older, more experienced nurses as “eating their young” (Participants 3, 5, 15, and 16). Participants stated that because they were comfortable adhering to policies and acting professionally, they were not mentioned in discussions about the problems new nurses presented. Being excluded from such conversations gave these newly graduated nurses confidence that made the transition from student to professional registered nurse more pleasurable. Experience and knowledge was a substantive category. Participants repeatedly expressed admiration for the vast knowledge nursing faculty presented, as well as nursing faculty’s ability to share knowledge and experience with students. Participants correlated nursing faculty knowledge with a desire to gain knowledge for themselves. 42 International Journal of Nursing, Vol. 2(2), December 2015 All the participants noted having a strong knowledge base eased their transition process. “Professor M . . . seemed to know everything. . . . Every time I . . . don’t know . . . the diagnosis . . . I [use her process] to quickly learn . . . the problems . . . that weren’t part of [patients’] diagnoses” (Participant 3). The final substantive category identified is professionalism. Participants spoke about poor nursing faculty behaviors and attitudes as being unprofessional. Nursing faculty identified as favorable were referred to as having those qualities that students expected registered professional nurses to have. “I think one of the best things that any of the professors did was treat us all like professionals from the start” (Participant 5).During member checking, participants were asked if nursing faculty attitudes affected their ability to adjust to the professional role. Participants noted how they aligned themselves with the actions of nursing faculty they believed represented professionalism. Discussion The purpose of this grounded theory research was to understand nursing faculty behaviors that influenced new graduate nurses’ability to have a successful role transition from student to professional registered nurse. Once understood, the Faculty Attributes for Confidence, Equilibrium, and Success (FACES) theory was developed. The intention of the FACES theory is to provide guidance to nursing faculty regarding which attributes and behaviors help the new graduate nurse decrease their anxiety and stress during their transition from student to registered professional nurse. Another intention is that when nursing faculty reflect upon individual actions and attributes while considering the components of the FACES theory, nursing education will be enhanced. Students should leave the academic setting prepared to meet the demands of the health care industry and successfully pass the NCLEX. Categories formed indicated nursing faculty’s caring attitude served as a guide to how the new graduate should act when working in a healthcare institution. Participants remarked on their confidence when they encountered unknown situations, as long as they remained calm and caring. They equated caring with nursing faculty taking time to view each student as an individual. Participants correlated the time nursing faculty took to care with a more inspiring learning environment. Nursing faculty’s caring approach to teaching also set an example for the new graduate nurse to follow in rendering patient care. Students were comfortable seeking help from nursing faculty who depicted a caring attitude. When content was difficult to understand, students sought assistance from nursing faculty they believed cared. These faculty simplified the difficult content, thus increasing the students’ knowledge base. The process of increasing students’ knowledge base through content simplification could increase new graduates’ power of inquiry. An increased power of inquiry and knowledge base might equate with an increase in learning throughout a nurse’s professional career (Benner et al., 2010). Study participants discussed professionalism and some nursing faculty’s unprofessionalism. Nursing faculty who laughed and acted facetiously outside the classroom, but maintained a professional tone in the classroom or clinical setting provided positive examples on how to remain professional and interact with colleagues in a relaxed manner. Participants admitted to liking a nursing faculty-student bond of friendship during the educational experience, and that the actions of nursing faculty who remained professional and caring in all situations served as a guide when adapting to the social structure of the health care industry. Nursing faculty’s responses in difficult or challenging situations provided a basis for decreasing anxiety and stress when the new graduate encountered unexpected or unknownsituations. Participants were inspired by the vast knowledge portrayed by nursing faculty. Disseminating knowledge using teaching methods such as narrative andragogy and real-life case studies motivated students to study harder, thereby developing a stronger knowledge base. The use of multiple technological venues in the classroom and clinical setting bolstered new graduates’ confidence in their ability to find and learn new information independently. Participants reported nurses with many years of experience complemented the new graduates and express pleasure in working with them. When these senior nurses expressed satisfaction with the new graduates’ actions, confidence was boosted, decreasing stress and anxiety. Experience was referred to in the context of clinical nursing experience, as well as with using multiple teaching, learning, and assessment techniques in the classroom and clinical setting. Participants noted the use of highstakes simulation with critical cases derived from actual nursing faculty experiences not only taught students content, but also how to use critical thinking and reasoning skills in high-pressure situations. The new graduates reported believing most of the situations they encountered when adjusting from the role of student to that of professional registered nurse were high-pressure circumstances. Lisa L. Sparacino 43 Having experienced functioning in high-stakes simulations reduced the new nurses’ anxiety and increased their ability to think critically instead of being frightened and flustered when caring for patients. Participants considered the capacity to critically think in challenging situations as a key component to a successful transition. Participants expressed dislike for nursing faculty who were strict and always adhered to policies without exception, but, once these former students assumed the role of professional registered nurse in the workplace, they appreciated the nursing faculty who adhered to rigor in policies, assignments, appearance, and punctuality. Participants explained that being expected to adhere to rigorous standards in school made it easy to adapt to workplace policies.The equilibrium of expectations enforced through rigor in school prepared new nurses to meet workplace expectations. Participants reported colleagues who found work policies overwhelming had educational experiencesin which rules were not routinely enforced. Many found having policies enforced on a case-by-case basis increased new graduates’ stress levels. Participants expressed that their colleagues who reported very high stress levels no longer worked with study participants in the hospital. Statements centered on nursing faculty having a caring attitude, adhering to rigor, treating all equally and fairly, possessing vast knowledge, incorporating personal experiences into teaching, and always portraying a sense of professionalism in actions led to the development of the Faculty Attributes for Confidence, Equilibrium, and Success (FACES) theory (Fig. 1).Participants indicated all five attributes are equally important. The five points of the star represent the individuality of each attribute. Arrows connecting the attributes indicate the need for all attributes to be present in the educational arena. Nursing faculty who demonstrate all five attributes in their behaviors decrease new graduate nurses’stress and anxiety in the transition from student to professional registered nurse. -----------------Insert Fig. 1 here ------------------Conclusions Reforming nursing education so students graduate better able to meet the demands of the health care industry is paramount. Nursing leaders have focused on revising content now and developing standards for nursing programs later (AACN, 2008; NLN, n.d.). The goal of this research was to develop a beginning theory identifying nursing faculty behaviors that influence nursing students, making the transition from student to professional registered nurse less stressful. Interviews with new nurses make it clear that transfer of information is not enough. Nursing faculty need to lead by example. Attributes that allow nursing faculty to lead by example led to development of the Faculty Attributes for Confidence, Equilibrium, and Success (FACES) theory. These characteristics, derived from strict adherence to the process of constant comparison, open coding, axial coding, and selective coding,are caring, professionalism, rigor, knowledge, and experience. Developing these physiognomies requires nursing faculty to become critically reflective of their teaching (Brookfield, 1995). It is reasonable to conclude thatit is imperative to new nurses’ successful transition that nurse educators fully develop a caring attitude, maintain professional behavior at all times, be fair and rigorous regarding policies and assignments, and maintain current knowledge and experience in the health care industry, as well as in the practice of adult education. Each characteristic represents an individual component ofthe holistic educational process. All five attributes must be present for students to perceive nursing faculty are mentors, as well as educators. The practice of nursing education today emphasizes knowledge acquisition and knowing without stressing learning in the context of clinical inquiry (Benner et al., 2012). The FACES theory provides guidance to nursing faculty on what is necessary to change how future nurses are educated. An education placing high value on nursing faculty leading by example decreases the stress and anxiety of reality shock, facilitating new graduates’ use of critical thinking and reasoning to provide safe patient care. Because successful orientation depends on new graduates possessing the knowledge and tools of an advanced beginner, possibly even nearing a competent practitioner, enhancing nursing education through implementation of the FACES theory may have a positive impact on patient outcomes. Study limitations include the researcher’s previously held assumptions, the participant pool, and use of grounded theory. It is assumed that information obtained from the participantspool in Ohio is transferable to all new graduate nurses throughout the United States. 44 International Journal of Nursing, Vol. 2(2), December 2015 Strict adherence to the rigor of grounded theory data collection and coding are recognized as reducing researcher bias and the methodology of grounded theory itself. Supplementary research is needed to further validate the theory. A quantitative inquiry relating a decrease in medical errors to a less stressful role transition would benefit nursing faculty, as well industry educators, to close the gap between education and professional practice. Educators who maintain caring, professional, and rigorous behavior, as well as current knowledge and experience, and portray these characteristics to students increase new graduates’ ability to enter practice prepared and confident to manage the social structure of the health care industry and achieve positive patient outcomes. Specific nursing facultybehaviors that increased new graduates’ self-efficacy and decreased symptoms of reality shock were identified, although measurable criteria such as the correlation between decreased reality shock and reduction in medical errors were not identified. Thisstudy captured beliefs related to the phenomenon of reality shock for new nurses in the north central and northeastern United States. Replicating this research in other areas of the United States andin other countries would improve credibility the FACES theory. Replicating this research by including second degree nurses, second career nurses, and older nurses entering their first career could also increase the credibility of these research findings. Increased knowledge and skill levels of new graduates exposed to these attributes have yet to be correlated. Can nursing faculty’s behaviors be linked to first-time pass rates on NCLEX? Could a reduction in medical errors be identified when new graduate nursesare better prepared for reality shock?It was unintentional that all of the new graduates who participated in this study were baccalaureate prepared. There is a need to study nursing faculty behaviors of new graduates who enter professional practice with an associate’s degree. 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Making a difference: The value of preceptorship programs in nursing education.Journal of Continuing Education in Nursing 43, 37–43. http://dx.doi.org/ 10.3928/00220124-20110615-01 Dyess, S. M., Sherman, R. O. (2009). The first year of practice: New graduate nurses’ transition and learning needs. Journal of Continuing Education in Nursing 40, 403–410. http://dx.doi.org/10.3928/00220124-20090824-03 Farner, S. M., Brown, E. E. (2008). College students and the work world.Journal of Employment Counseling 45, 108– 114. http://dx.doi.org/10.1002/j.2161-1920.2008.tb00050.x Fero, L. J., Witsberger, C. M., Wesmiller, S. W., Zullo, T. G., Hoffman, L. A. (2009).Criticalthinking ability of new graduate and experienced nurses. Journal of Advanced Nursing 65, 139–148. http://dx.doi.org/10.1111/j.1365-2648.2008.04834.x Gentile, D. L. (2012).Applying the novice-to-expert model to infusion nursing.Journal of Infusion Nursing 35, 101– 107. http://dx.doi.org/10.1097/NAN.0b013e3182424336 Glaser, B. G. (1998). Doing grounded theory: Issues and discussions.Sociology Press, Mill Valley. Glaser, B. G. (2003). The grounded theory perspective: Conceptualization contrasted with description. Sociology Press, Mill Valley. 46 International Journal of Nursing, Vol. 2(2), December 2015 Glaser, B. G., Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. Aldine, Piscataway. Greene, M. A. (2010). Paying for nursing orientation.Journal of Nurses in Staff Development 26(6), E3–E7. http://dx.doi.org/10.1097/NND.0b013e3181fc0459 Kramer, M. (1974). Reality shock: Why nurses leave nursing. Mosby, St. Louis. Lampe, K., Stratton, K., Welsh, J. R. (2011). Evaluating orientation preferences of the Generation Y new graduate nurse.Journal for Nurses in Staff Development 27, E6–E9. http://dx.doi.org/10.1097/NND.0b013e3182236646 Martin, K., Wilson, C. B. (2011). Newly registered nurses’ experience in the first year of practice: A phenomenological study. International Journal for Human Caring 15(2), 21–26. Retrieved from http://www.humancaring.org/journal/ Morrow, S. (2009). New graduate transitions: Leaving the nest, joining the flight. Journal of Nursing Management 17, 278–287. http://dx.doi.org/10.1111/j.1365-2834.2008.00886.x Morse, J. M., Field, P. A. (1995). Qualitative research methods for health professionals, seconded.Sage: Thousand Oaks, CA. Myrick, F. (1988). Preceptorship: A viable alternative clinical teaching strategy? Journal of Advanced Nursing, 13, 588–591. http://dx.doi.org/10.1111/j.1365-2648.1988.tb01452.x National Council of State Boards of Nursing (NCSBN). (n.d.).Transition to practice. Retrieved January 16, 2015, from https://www.ncsbn.org/transition-to-practice.htm National League for Nursing (NLN).(n.d.).NLN competencies for nursing education. Retrieved January 16, 2015, from http://www.nln.org/facultyprograms/competencies/ Oberg, K. (1960). Cultural shock: Adjustment to new cultural environments. Practical Anthropology 7, 142–146. Retrieved January 16, 2015, from http://agem-ethnomedizin.de/download/cu29_2-3_2006_S_142146_Repr_Oberg.pdf Pinchera, B. J. (2012). Newly licensed nurses: A look at their first 18 months.Nursing 42(5), 18–22. http://dx.doi.org/10.1097/01.NURSE.0000413625.74733.f8 Roberts, K., Lockhart, R., Sportsman, S. (2009).A competency transcript to assess and personalize new graduate competency. Journal of Nursing Administration 39, 19–25. http://dx.doi.org/10.1097/NNA.0b013e31818e9d2b Roy, C., Sr. (1988). An explication of the philosophical assumptions of the Roy adaptation model.Nursing Science Quarterly 1,26–34. http://dx.doi.org/10.1177/ 089431848800100108 Roy, C. Sr., Andrews, H. A. (1991). The Roy adaptation model: The definitive statement. Appleton & Lange, Norwalk. Saintsing, D., Gibson, L. M., Pennington, A. W. (2011). The novice nurse and clinical decision-making: How to avoid errors. Journal of Nursing Management 19, 354–359. http://dx.doi.org/10.1111/j.1365-2834.2011.01248.x Schempp, C. M., Rompre, R. M. (1986). Transition programs for new graduates: how effective are they? Journal of Nursing Staff Development2(4), 150–156. Retrieved from http://journals.lww.com/jnsdonline/pages/default.aspx Strauss, A. L., Corbin, J. M. (1990). Basics of qualitative research: Grounded theory procedures and techniques. Sage, Newbury Park. Strauss, A. L., & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory, seconded. Sage: Thousand Oaks CA. Should Nurses Blow the Whistle or Just Keep Quiet? Carolyn Buppert, MSN, JD June 24, 2014 To submit a legal/professional nursing question for future consideration, write to the editor at syox@medscape.net (Include "Ask the Expert" in subject line.) Question What should I do when I discover that something happening at my facility is a threat to patient safety? Response from Carolyn Buppert, MSN, JD Healthcare attorney Confused? I'm Not Surprised Apparently, a lot goes on in healthcare that makes nurses uncomfortable, because I am asked this question, in some form, frequently. The answer is complicated. People may differ in their opinions of what falls into the realm of incompetent, unethical, or unsafe practice, and the laws of every state are different. And even though I read law every day, I had trouble figuring out what to advise, given the current law governing nurses. No wonder nurses aren't sure what to do. Nurses are told that they have a duty to protect patient safety. They learn this from language such as this, in one state's (Maryland) nursing regulations. Under "Ethical Responsibilities," it says: "A nurse shall...Act to safeguard a client and the public if health care and safety are affected by the incompetent, unethical, or illegal practice of any person."[1] The implication is that when a nurse becomes aware of a patient safety threat, the nurse is supposed to do something. Maryland is not alone in making such pronouncements. Here is language from the Texas Board of Nursing Website: Situations involving potential risk of harm to patients or the public are referred to as "violating the nurse's duty to the patient" because all nurses have a duty under Rule 217.11(1)B to maintain a safe environment for patients/clients and others for whom the nurse is responsible.[2] It makes sense to tell nurses that they are expected to safeguard patient safety. It would be even better if nurses who try to do something were better rewarded for their efforts. However, according to nurses I hear from, when a nurse reports a patient safety problem, the nurse often is surprised to find that he or she is considered the "bad guy." A nurse who raises quality issues that require a change of policy, practice, or staffing can be seen as a disruptor rather than someone who is making constructive criticism. Some nurses who have identified problems have found themselves out of a job. This is bothersome. It's perfectly legal for a hospital to terminate a nurse, for any reason or for no reason. The only job protections are those granted by contract between the nurse and the hospital (whether it is an individual contract or a contract offered through a labor union) and those granted by the US Constitution and civil rights laws. The latter include the right to be free of discrimination on the basis of age, sex, national origin, race, sexual orientation, and religious preference. If the hospital isn't firing the nurse because of age, sex, national origin, race, sexual orientation, or religious preference, in general the firing is legal. A possible exception is a whistleblower law, which may, in some situations, provide protection for nurses who report patient safety problems. We will get to that shortly. Although it is legal to fire a nurse for raising a patient safety issue (with a possible exception of whistleblower laws) it is not a situation one would hope for, from a patient's perspective. Blowing the Whistle, Fighting the System The following story is an example of a case in Texas where nurses were very concerned about the care being provided by a physician at their hospital, did something about it, and suffered as a result. Two nurses, one of whom was the hospital's compliance officer, reported a hospital physician to the state medical board, citing patient safety issues. The problems, according to the source listed below, included the following: (1) The physician was taking patients with serious diagnoses off their medications and instead recommending herbal remedies, for which he was the vendor; (2) the physician was performing surgery, including a skin graft, in the emergency department, even though he wasn't a surgeon; and (3) the physician almost never read patient charts nor ordered diagnostic testing, preferring instead to diagnose on the basis of history alone. The nurses who reported him essentially were relaying the observations and complaints of many nurses. The nurses filed an anonymous report with the medical board. Once the medical board contacted the physician, the physician enlisted his friend, the sheriff, to do some digging, and the sheriff found out who had filed the complaint against the physician. The physician then filed a complaint, with the sheriff, against the nurses, for harassment. The sheriff arrested the nurses, and the local prosecutor charged them with "misuse of official information," a felony punishable by 10 years in prison. (They had accessed patient charts to describe, specifically, the threats to patient safety.) The prosecutor had a few conflicts of interest. He was not only the doctor's personal attorney, but also the personal attorney for the sheriff and the hospital's counsel. The physician convinced the hospital to fire the nurses. Eventually the case went to trial against one of the nurses, and she was found not guilty. Charges against the other nurse were dropped before her trial, for reasons unspecified. As of 1 year later, the physician still was working at the hospital. Much later, the sheriff, the hospital administrator, and the prosecutor all were prosecuted for misuse of official information (the same charge that had been applied to the nurses), and all were found or pleaded guilty. The nurses sued the hospital and received a settlement. Eventually, the physician too was charged with misuse of official information and retaliation. He pleaded guilty. The full story can be heard on the radio program Old Boys Network, which originally aired on June 3, 2011. A transcript is also available. The nurses in this case were vindicated, but both went through several years of extreme stress, joblessness, and legal fees. Reportedly, neither wants to be a nurse any longer. Whistleblower Laws A nurse who is fired for bringing up a patient safety issue may think he or she is protected against retaliation under a "whistleblower law," but in fact, the nurse may not be protected. Whether such protection exists depends on exactly what the state's whistleblower law covers; whether the nurse followed the dictates of the law precisely; and whether there was any other reason, aside from reporting the patient safety issue, for which the hospital could reasonably have fired the nurse. The following case illustrates what can happen when a nurse tries to rely on a whistleblower law.[3,4] A hospice nurse reported to her supervisors that starter packs of controlled drugs were being given to patients without a physician's order. She was worried because some of the patients were children and because she feared the drugs would be misused. Shortly after she complained about this practice, she was fired. She was denied unemployment compensation because she had been fired. She protested the denial of unemployment and filed for wrongful termination, hoping to use the state's Health Care Worker Whistleblower Protection Act. The nurse found that the purpose of that law wasn't to protect nurses, but to protect employers against frivolous whistleblower actions filed by disgruntled former employees. A judge found that she hadn't conformed with a provision of the law, so the law didn't apply. (She hadn't reported the problem to an outside agency -- only to individuals within the agency.) The state's highest court reversed the finding of the lower court, holding that it was enough to have reported the problem internally, and essentially said she could avail herself of the whistleblower law. However, when the case was tried, a jury believed the hospice, her employer, who argued that they terminated the nurse for a reason other than the complaint about the starter packs. The jury believed that the nurse was right in making the complaint, but that didn't help the nurse, ultimately. The nurse spent $150,000 on her legal efforts. Maryland's Whistleblower Protection Act didn't work for that nurse, but let's look at another state's whistleblower protection for nurses. It appears that Texas law has some protections for a nurse who reports a quality issue[5]: A nurse may report to the nurse's employer or another entity at which the nurse is authorized to practice any situation that the nurse has reasonable cause to believe exposes a patient to substantial risk of harm as a result of a failure to provide patient care that conforms to minimum standards of acceptable and prevailing professional practice or to statutory, regulatory, or accreditation standards. For purposes of this subsection, an employer or entity includes an employee or agent of the employer or entity. A person may not suspend or terminate the employment of, or otherwise discipline, discriminate against, or retaliate against, a person who: (1) reports in good faith under this section; or (2) advises a nurse of the nurse's right to report under this section. This law was added in 2011, after the Texas case described earlier. The key is to research the law of your state, so you know up front whether you have any protections when complaining about a patient care issue. In a recent article [6] a nurse-attorney and a social worker who have experience with whistleblowers discourage nurses from whistleblowing, for their own good. Federal whistleblower protection acts exist, which are meant to encourage reporting of healthcare fraud, and if the nurse follows the exact provisions of these laws, the nurse may share in the government's recovery of money. That is a different subject, however, and not addressed here. The Nurse's Duty to Protect Patient Safety What if a nurse doesn't report a quality of care or patient safety issue? Is he or she likely to be disciplined? Let's look at Texas law on reporting. It appears that reporting of a patient safety issue involving an agency or facility problem is optional ("may report"), but reporting of another nurse is mandatory ("shall report"). Here is the language that says reporting a facility is optional [7]: In a written, signed report to the appropriate licensing board or accrediting body, a nurse may report a licensed health care practitioner, agency, or facility that the nurse has reasonable cause to believe has exposed a patient to substantial risk of harm as a result of failing to provide patient care that conforms to:  (1) minimum standards of acceptable and prevailing professional practice, for a report made regarding a practitioner; or  (2) Statutory, regulatory, or accreditation standards, for a report made regarding an agency or facility. Here is the language that says reporting a nurse is mandatory in Texas:  (1) "Conduct subject to reporting" means conduct by a nurse that: o (A) violates this chapter or a board rule and contributed to the death or serious injury of a patient; o (B) causes a person to suspect that the nurse's practice is impaired by chemical dependency or drug or alcohol abuse; o (C) constitutes abuse, exploitation, fraud, or a violation of professional boundaries; or o (D) indicates that the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse's continued practice of nursing could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of behavior.[8] A nurse shall report to the Board in the manner prescribed under Subsection (d) if the nurse has reasonable cause to suspect that:  (1) another nurse has engaged in conduct subject to reporting; or  (2) the ability of a nursing student to perform the services of the nursing profession would be, or would reasonably be expected to be, impaired by chemical dependency.[9] Under Texas law, therefore, the nurse may, but has no obligation to, report a facility to the appropriate licensing board, when the nurse has reason to believe that a patient has been exposed to substantial risk for harm. But a nurse must report another nurse. Here is what Texas law says about failure to report: "(a) A person is not liable in a civil action for failure to file a report required by this subchapter. (b) The appropriate state licensing agency may take action against a person regulated by the agency for a failure to report as required by this subchapter.[10] In Texas, the Board of Nursing could take action against a nurse who failed to report, but isn't required to do so. Let's go back to the state law language cited earlier that implies that nurses must safeguard patient safety. A search of the disciplinary actions of the Maryland Board of Nursing indicates that the language "a nurse shall act to safeguard a client..." is invoked when it is the nurse who is incompetent or unethical. The nurse is supposed to report him- or herself, but not necessarily report someone else, or a facility. I found no cases where that clause was used to discipline a nurse who discovered that someone else was incompetent, and failed to report it. I could find no disciplinary actions reported on the Texas Board of Nursing Website against nurses who had failed to report a patient safety issue. Other states may have different law on this, or no law on this, but it is becoming clear that a nurse doesn't have to report a facility and will do better personally if he or she does not. So, Don't Report? Am I recommending that nurses adopt the "see nothing, hear nothing, speak nothing" attitude? No. I am saying that under current law, it is safer for a nurse not to report than to report. That surprises me, and it may be rightor wrong-minded, but it's the way it is. To argue the hospital or facility's side, a facility can't have every nurse they fire come back and say he or she was fired because the nurse complained about a patient safety issue. Hospitals will lobby legislators for laws that protect the hospital. And a hospital is going to defend itself against allegations of breach of patient safety, even if that means firing a nurse and discrediting the nurse. In all fairness, with every safety issue that a nurse might identify, there usually is an opposing argument that it isn't a safety issue or is a necessary risk. And some nurses are vulnerable to being discredited because they don't have spotless records. My purpose in this article is to inform nurses of the things they must do to protect themselves, before complaining, both within their company and to outside agencies. First, check your state's Nurse Practice Act for any law on reporting patient safety issues. Also check the state's Board of Nursing Website for any direction on this. Then, look at the whistleblower laws for your state, if there are any. If you decide to blow the whistle, follow the dictates of the law, exactly. Gather your evidence. Keep detailed records. I urge nurses to conduct a safety analysis on themselves before blowing the whistle on safety problems in the workplace, and even before complaining. I don't like to see nurses get nowhere with their patient safety concerns and also suffer personal setbacks. It is smart to consult an attorney who is experienced in whistleblower cases before complaining. (I am not an expert on whistleblower cases.) It may be best to line up your next job before complaining to higher-ups. Think before you act. Spend some time thinking about how to raise the issue, and with whom to raise it. Read some of the many books about the ins and outs of workplace communication. Watch and listen, and observe individuals in your workplace who seem skilled at working with others to effect change. It may be best to frame complaints as volunteering to help solve a problem. I don't know of a "charm school" for nurses, but if there is one, I would enroll and would encourage others to do so. Consider your risk. Be sure that your own practice is in order. If you complain about a policy or practice at your facility and someone wants to get back at you, what would they say? What are your vulnerabilities? Assess the gravity of the problem. If the problem you have identified is putting a patient or employee at imminent and serious risk, you may need to put all thoughts of yourself aside and report it. If the risk isn't so serious or isn't so imminent, then perhaps volunteering to problem-solve is in order. Assess the administration and your supervisors. Is there someone you can talk to in confidence whom you trust? Is there a financial reason why the problem is present? If so, be prepared for a struggle, unless you can suggest a legal, more cost-effective alternative. Taking a big-picture view, I recommend that nurses, throughout their careers, safeguard their ability to find another job, if they need to. Cultivate people who will give you positive references throughout your career, and do the same for them. This means treating colleagues professionally, not sharing personal dramas at work, keeping up with the latest developments in the field, handling disagreements in a way that doesn't leave others feeling bruised, and going up the chain of command when necessary. Conduct periodic self-assessments to identify your own vulnerabilities, and make a plan to minimize them. The bottom line is: It's always better to prevent problems, in law as well as healthcare. References 1. Maryland Office of the Secretary of State. Code of Maryland Regulations (COMAR) 10.27.19.02.A(3). Ethical responsibilities. http://www.dsd.state.md.us/comar/SubtitleSearch.aspx?search=10.27.19 Accessed June 13, 2014. 2. Texas Board of Nursing. Texas Administrative Code. Rule §217.11 Standards of nursing practice. http://www.bne.state.tx.us/rr_current/217-11.asp Accessed June 13, 2014. 3. Lark v. Montgomery Hospice, Inc. 994 A.2d 968 (Md 2010). Court Listener. https://www.courtlistener.com/md/bvbz/lark-v-montgomery-hospice/ Accessed June 13, 2014. 4. Arias J. Fired nurse loses wrongful termination lawsuit against Montgomery Hospice. Gazette.net: Maryland Community News. June 19, 2011. http://www.gazette.net/article/20110629/NEWS/706299494/1081/fired-nurse-loses-wrongful-terminationlawsuit-against-montgomery&template=gazette Accessed June 13, 2014. 5. Texas Board of Nursing. Texas Nursing Practice Act. Sec. 301.4025(b). http://www.bne.state.tx.us/npa1.asp#411 Accessed June 13, 2014. 6. Phillipsen NC, Soeken D. Preparing to blow the whistle: a survival guide for nurses. Journal for Nurse Practitioners. 2011;7:740-746. http://www.medscape.com/viewarticle/751347 Accessed June 13, 2014. 7. Texas Board of Nursing. Texas Nursing Practice Act. Sec. 301.4025(a). http://www.bne.state.tx.us/npa1.asp#411 Accessed June 13, 2014. 8. Texas Board of Nursing. Texas Nursing Practice Act. Sec. 301.401(1) http://www.bne.state.tx.us/npa1.asp#411 Accessed June 13, 2014. 9. Texas Board of Nursing. Texas Nursing Practice Act. Sec. 301.402(b). http://www.bne.state.tx.us/npa1.asp#411 Accessed June 13, 2014. 10. Texas Board of Nursing. Texas Nursing Practice Act. Sec. 301.411(a). http://www.bne.state.tx.us/npa1.asp#411 Accessed June 13, 2014. Medscape Nurses © 2014 WebMD, LLC Cite this article: Carolyn Buppert. Should Nurses Blow the Whistle or Just Keep Quiet? Medscape. Jun 24, 2014. The First Year of Practice: New Graduate Nurses’ Transition and Learning Needs Susan M. Dyess, PhD, RN, and Rose O. Sherman, EdD, RN, NEA-BC, CNL abstract Although the phenomenon of reality shock has been acknowledged as part of the new graduate nurse transition for decades, there is evidence to suggest that the problems with the transition into practice are more serious today. This article presents findings about the new graduate nurse transition and learning needs from qualitative research conducted in a community-based novice nurse transition program. The new graduate nurse transition and learning needs are examined through the eyes of new graduates and the nursing leaders and preceptors who work with them. Recommendations are offered for continuing education initiatives that can be designed to meet these needs. J Contin Educ Nurs 2009;40(9):403-410. T he practice readiness of new graduates is a topic that generates lively conversation and divergent viewpoints among nurse educators in academic and practice settings. Although the phenomenon of reality shock has been acknowledged as part of the new graduate nurse transition for decades (Kramer, 1974), there is evidence to suggest that the problems with the transition into practice are more serious today. Prior to the initiation of computerized licensure testing in 1994, new graduates entered practice with provisional licenses, working with seasoned nurses for a number of months. New graduates in today’s environment can take the licensure examination within weeks of graduation and enter practice as fully licensed registered nurses almost immediately. An unintended consequence of this change has been the rapid deployment of new graduates into clinical settings where they assume profes- sional responsibilities that potentially are beyond their capabilities (Burns & Poster, 2008; Del Bueno, 2005; Li & Kenward, 2006; Spector & Li, 2007). This change has been made even more problematic by the rising acuity of today’s hospital patients, reduced lengths of stay, staffing shortages, and complex new technologies. In this era of cost containment, there have been greater demands on nurse leaders in practice settings to shorten new employee orientations and move new staff into patient care assignments more rapidly. Health care agencies and the American Association of Colleges of Nursing (AACN) now realize the effect of the influx of new graduates, and many efforts are being made to improve the orientation of novice nurses (AACN, 2005; Salt, Cummings, & Profetto-McGrath, 2008; Williams, Goode, Krsek, Bednash, & Lynn, 2007). The National Council of State Boards of Nursing (NCSBN) has developed an evidence-based regulatory model for transitioning new nurses into practice that they hope to see adopted across the United States through licensure regulation (NCSBN, 2008). It is the vision of the NCSBN that new graduates will be required to provide their state board of nursing with evidence of Dr. Dyess is Project Director, Novice Nurse Leadership Institute; and Teaching and Research Associate, Florida Atlantic University, Christine E. Lynn College of Nursing, Boca Raton, Florida. Dr. Sherman is Robert Wood Johnson Executive Nurse Fellow; Director, Nursing Leadership Institute; and Assistant Professor, Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida. The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. Address correspondence to Susan M. Dyess, PhD, RN, Florida Atlantic University, 777 Glades Road, Christine E. Lynn College of Nursing NU357, Boca Raton, FL 33431. doi:10.3928/00220124-20090824-03 The Journal of Continuing Education in Nursing · September 2009 · Vol 40, No 9 403 Sidebar 1 Novice Nurse Leadership Institute Topics for the 20 Educational Sessions 1. Self-Knowledge. Incorporates diagnostic tools for a leadership mindset (foundational thinking skills) as well as leadership and personality style. 2. Leadership. A discussion of leadership theory, definitions, and systems thinking. 3. Technical Skill Augmentation and Procedural Ease. Simulation and laboratory time. 4. Interpersonal and Communication Effectiveness. Role-playing centered on interdisciplinary collaborative interaction and challenging patient and family situations. 5. Clinical Judgment. Discussion of the competencies of patient-centered care, clinical decision-making, and shared decision-making. 6. Professionalism. Incorporates a discussion of the competencies of advocacy and accountability, linking them to daily practice. 7. Knowledge of the Health Care Environment. Incorporates a discussion of governance structures and work design. 8. Cultural Diversity and Sensitivity. Addresses cultural competency in relation to professional colleagues, patients, and their families. 9. Safe Practice. Highlights the principles of safety as they relate to patient outcomes. 10. Business Skills and Principles. Incorporates a discussion of health care economics and financing and links these concepts to nursing practice. 11. Knowledge of Evidence and Research. Incorporates the competencies of systems thinking, health care policy, patient safety, quality, and evidence-based practice. 12. Strategic Vision: Our Current and Future Health Care World. Considers the regulatory organizations affiliated with health care and their effect. 13. Creativity and Innovation in the Practice Setting. Considers translation of evidence and incorporates the competency of change management. 14. Leadership: Leadership Revisited. Incorporates a discussion of each novice nurse’s personal journey in leadership and explores the challenges therein. 15. Caring for Self. Highlights the importance of intentional self-care for nurse leaders. 16. Relationship Management. Focuses on the interdisciplinary collaboration that exists within health care and addresses principles of delegation. 17. Ethical Practice. Addresses the ethics of nursing care and considers dilemmas that exist. 18. Inspiring and Leading Change. Allows participants to present their evidence-based projects, followed by a group discussion of findings. 19. Engagement With Nurse Leaders. Offers panels of nurse managers, nurse directors, and chief nursing officers the opportunity to connect directly with new nurses. 20. Career Success and Advancement. Incorporates the competencies of career planning, professional development, and personal goal-setting. completing all of the requirements of this standardized transition program to maintain their license after their first year of practice. With this heightened interest in transition programs and possible future regulatory requirements, nurse educators in practice settings are reexamining their approaches to new graduate nurse orientation. This article presents findings about new graduate nurse transition and learning needs from qualitative research conducted in a community-based novice nurse transition program. New graduate nurse transition and learning needs are examined through the eyes of new graduate nurses and the nursing leaders and preceptors who work with them. Recommendations are offered for continuing education initiatives that can be designed to meet these needs. Background In the United States, successful completion of a nursing education program and achievement of a pass404 ing score on the National Council Licensure Examination-Registered Nurse are required to demonstrate entry-level competence to begin nursing practice (NCSBN, 2008). Although newly licensed nurses have achieved the legal and professional requirements of minimal competence to enter practice, studies indicate that many new nurses lack the clinical skills and judgment needed to provide safe, competent practice (Del Bueno, 2005; Li & Kenward, 2006). New graduates express concerns about their ability to provide safe patient care and meet the performance expectations of the organizations that employ them (Casey, Fink, Krugman, & Propst, 2004; Duchscher, 2001; Halfer & Graf, 2006). These concerns are shared by nursing leaders. In a recent survey conducted by the Advisory Board Company, only 10% of hospital and health systems nurse executives believed that their new graduates were fully prepared to provide safe care (Berkow, Virkstis, Stewart, & Conway, 2009). The Journal of Continuing Education in Nursing · September 2009 · Vol 40, No 9 Although the transition into practice can be exhilarating initially, the experience often becomes traumatic during the first year as new graduates experience the real world of health care (Duchsher & Cowin, 2004). Community discussions among nursing leaders in the authors’ area related to the apparent disconnect between nursing education and practice led to the development of a grant-supported Novice Nurse Leadership Institute (NNLI) in South Florida. The NNLI is a university-based, but practice-informed 1-year transition program that is now in the third year of operation, with novices attending from 13 partner agencies. The overarching goals of the program are to strengthen the competencies of new nurses along a variety of dimensions, provide ongoing support to reduce turnover in the first year of practice, and create a pool of future nurse leaders to serve the community by developing a leadership mindset in the first year of practice. Feedback from the new nurses about their experiences and transition has been an important part of the project’s success and development. The research presented in this article about novice nurses’ first-year practice experiences and learning needs is based on program evaluations and findings from focus groups conducted between 2006 and 2008 with new graduate nurse participants, preceptors, and nursing leaders. Program Planning As initial planning began for the NNLI program, partnership members agreed that the program would not replace individual facility orientation or other unit-based transition initiatives. Rather, it could serve as a strong recruitment tool for high-potential new graduates and augment organizations’ basic orientation efforts. Prior to the beginning of program design, focus groups were held with chief nursing officers, new graduate preceptors who had varied educational preparation, and staff nurses. To better meet the needs of practice environments, focus group participants recommended that content be developed to enhance the clinical judgment of new graduates and increase their confidence with basic clinical skills. Nurse leaders wanted a transition program that would build on what new nurses had learned in their education programs in the areas of patient safety, communication proficiency, delegation, and health care systems thinking. A review of the literature about new graduate nurses’ learning needs was also conducted. The leadership content was developed using resources such as the American Organization of Nurse Executives competencies (2005) and the Robert Wood Johnson Executive Nurse Fellows competencies (Morjikian & Bellack, 2005). The cur- Sidebar 2 Reflective Dialogue Questions for Web Discussion • How are nursing policies determined within your organization? • How do nurses contribute to the policy-making process? • From your perspective, what are the opportunities for improvement in your health care organization? • What types of decisions do you find yourself making most frequently in your practice setting? • What kinds of clinical tasks are you delegating? How does that work? • How do you find support for clinical decisions? • Identify three areas you want to work on for your personal leadership development. • How does your practice setting use and incorporate research into practice? • Describe the training your organization offers for cultural diversity. riculum was developed to include 20 full-day learning sessions (Sidebar 1) delivered two Fridays each month across 12 months. The live learning sessions were complemented by asynchronous dialogues on a Web-based blackboard site (Sidebar 2). Program Participants The program participants were selected by the partner sites using general guidelines developed by the partnership. Participants were graduates with either an associate’s degree or a baccalaureate degree from various educational programs, and all had less than 12 months of practice experience. A high potential for professional and leadership contributions was an attribute that organizations were asked to use in their selection process. Candidates needed to commit to attend all of the sessions and complete an evidence-based project. The first three classes of NNLI included 81 participants. The mean age of the participants was 32 years. Demographic data for the participants is provided in the Table. The novice nurses worked in diverse practice settings, with 80% being acute care community facilities within a range of specialty areas. New Graduate nurses’ Learning Needs and Transition Experiences To better understand the learning needs and transition experiences of new graduate nurses, a qualitative research study was designed involving pre- and postprogram focus groups and using hermeneutic analysis. Experienced focus group facilitators with no connection to the program conducted the sessions. Institu- The Journal of Continuing Education in Nursing · September 2009 · Vol 40, No 9 405 Sidebar 3 Table SemiStructured Questions used for New Graduate nurse Focus Groups Novice Nurse Leadership Institute Participants (N = 81) Age (yr) Mean 32 Range 22 to 59 Gender Female 93% Male 7% Highest level of nursing education Bachelor of science in nursing 51% Associate’s degree 49% Ethnicity White 65% African-Caribbean 12% Hispanic 9% Black 7% Other (Asian, Native American, Indian) 7% Clinical area of assignment Medical-surgical, oncology, neurology, orthopedics 23% Telemetry 22% Hospice 2% Intensive care unit 14% Emergency department 13% Labor and delivery 12% Neonatal intensive care unit, pediatric intensive care unit, pediatrics 10% Operating room 4% tional review board approval was granted annually by Florida Atlantic University. Focus group participants were asked a set of semistructured questions (Sidebar 3). Sessions were audiotaped and then transcribed. Key themes and emerging patterns were coded from multiple reviews of data. Seven key themes involving the learning needs of new graduate nurses were identified from the data analyzed. The key themes, along with recommendations to consider when developing new graduate transition programs, based on the lessons learned from this study, are discussed. Confidence and Fear When asked to share their experiences as new graduate nurses, the participants reported feeling both confident and fearful. One participant described her experience as a new nurse as: “Excited and scared, definitely 406 • How would you describe yourself as a new nurse? • What topics/discussion/content areas do you suggest for the Novice Nurse Leadership Institute program to support you in your practice? • What are some of the best things and worst things about being a nurse? • What is going on in your practice setting? • Describe your typical workday. • Share some of your new nurse experiences that are memorable. scared, very excited and good to be where I am and happy to be with the patients, but definitely scared also.” Another participant shared her understanding of the new nurse experience as a synthesis of knowledge and emotion: “And I find it’s a fusion, a mix of fear for being the responsible one, and a challenge; to put all my knowledge properly together in every situation, and then it’s a wonderful achievement.” The combination of fear and confidence appears to stem from recognition of all they had learned in their educational programs and an anticipation of the unknown in patient situations. The participants also spoke of their determination and commitment to “do their time, whatever it takes” as a new nurse to transition successfully into practice. They expressed confidence in their own abilities and hope that there would be organizational systems in place to support their emotional growth in areas where they needed development. Recommendation: Support Throughout the First Year. New graduate nurse transition programs are typically designed to be completed within 3 to 6 months. The current findings suggest that new graduates would benefit from longer-term support that includes further development of clinical judgment, debriefing opportunities, and skill set enhancement. One nurse described starting as a nurse: “It’s really like you’re acting like a nurse, but you’re not really a nurse.” This recommendation for long-term support is consistent with the theoretical stage of acquiring clinical competence that acknowledges that novice nurses do not have the explicit understanding of the brand-new situations in which they are expected to perform (Benner, 1984). Further, the current findings support the conceptual framework of new graduate nurse transition proposed by Duchscher (2008), which suggests that new graduates move through three stages (doing, knowing, and being) during their first 12 months of practice and need support during each stage. During the course The Journal of Continuing Education in Nursing · September 2009 · Vol 40, No 9 of the NNLI, the new nurses were observed to move in and out of phases, and they ultimately recognized the benefit they received from the consistent collegial support provided by the program. The importance of long-term support was prominently illustrated by this statement made by a nurse as she exited the NNLI: “If it weren’t for this NNLI, I never would have made it as a new nurse. Never.” Extended support throughout the first year that respects the developing skills of the new nurse and allows for honest reflection on practice in group discussions with other new graduates is recommended. Less Than Ideal Communication New graduates in the focus groups reported frequent experiences of less than ideal communication with physicians and other interdisciplinary team members. One novice shared an experience that many other participants agreed had also happened to them: “And so finally I got him on the phone and started to explain the patient situation. He immediately cut me off and said, ‘I am making rounds. It can wait until I get there.’ And that was it. He hung up. I was simply reporting an abnormal lab value, trying to advocate for my patient. The response was so rude. You would think I did something wrong.” The lack of professional confidence that new graduates often feel can be heightened when another professional uses a gruff tone or expresses disgust. This is a patient safety issue because this sense of insecurity can contribute to the novice electing to avoid contacting the physician unless a patient experiences an extreme physiological decline (Rosenstein & O’Daniel, 2008). New graduate nurses also expressed concern about their ability to supervise and delegate to unlicensed assistive personnel. They reported situations in which individuals refused to cooperate with requests for assistance or passively ignored call bell lights. The new graduates were unprepared to deal with this type of conflict. One novice nurse reflected: “I would rather just ignore them and do it myself than get into it with someone.” All agreed that at some point they experienced a situation in which unlicensed staff did not respond to their requests and they chose not to confront the situation. Many commented that they did not feel equipped to explore the conflict appropriately and professionally. Recommendation: Interdisciplinary Communication Skills. As part of their orientation, new graduates typically receive some training in interpersonal communication skills. The current findings indicate that they need enhanced communication skill training that includes interdisciplinary role-play conversations and conflict resolution. New nurses benefit from intentional preparation for crucial conversations with other health care providers. Simulations that illustrate and give new graduates opportunities to practice collegial and professional communication in a safe setting, with debriefing and feedback, are very helpful. This need is illustrated by a new graduate who reported: “I want to know that I could respond to them, and know that I could stick up for myself, and that I have the right to, and know the words to say to them.” Experiencing Horizontal Violence New graduates in the current study reported frequent experiences with horizontal violence in the workplace. Horizontal violence is defined as any act of aggression demonstrated by a colleague, and it is inclusive of emotional, physical, and verbal threats, as well as innuendo or criticism (Longo & Sherman, 2007). In each focus group session, one participant would typically initiate the sharing of a difficult situation that occurred, and then choruses of NNLI participants confirmed that they too experienced unsupportive and unkind nurses in their practice settings. “It is the attitudes. It’s bipolar sometimes. Like you don’t know if they are having a bad day or if . . . they are happy or not or should it be like this or that . . . . They talk about the night shift, the day shift. They talk about you. They’re mean.” Although leaders in organizations tell new graduates that they promote zero tolerance of horizontal violence, the new graduates observe that this behavior continues and is often tolerated by nurse leaders at the unit level. Recommendation: Provide Strategies for Responding. New nurses may be unprepared to react appropriately to acts of horizontal violence. Specific information about horizontal violence should be shared with them, along with strategies for how to respond. It is important for transition programs to include scripted responses for new graduates to use in these situations; in addition, an opportunity should be provided for practice and roleplay. Perception of Professional Isolation Today’s health care environments are often extremely chaotic. In the midst of the chaos, new graduates can feel overwhelmed and professionally isolated. The new nurses reported multiple occasions when they perceived themselves as being utterly alone in their role as nurse, and these experiences influenced them greatly. This is illustrated by the comments of one nurse in a focus group: “It was a bad experience for me. The unit was so busy and no one stopped to notice anyone else. I felt so alone.” Another nurse shared a vivid description of not The Journal of Continuing Education in Nursing · September 2009 · Vol 40, No 9 407 Sidebar 4 National Council of State Boards of Nursing (2008) Transition to Practice: Recommended Modules • Specialty training • Communication • Safety • Clinical reasoning • Prioritizing/organizing • Research use • Role socialization • Delegating/supervising knowing what to do in a patient situation and seemingly not having anyone to guide her because everyone else was busy and she was on night shift. Recommendation: A Link to Leadership. New graduates have reported that they feel less alone when they have direct contact and conversations with nurse leaders in their organizations. As is true of other members of their millennial age cohort, new graduates want visibility and transparency from their nursing leadership. A formalized link to high-level nursing leadership enables new graduates to receive constructive feedback and promotes mutual professional dialogue. One nurse stated in a focus group: “I know that our chief nursing officer would be a little surprised at the experiences. I think if she heard first-hand how we feel, maybe that would help with some things in the hospital.” We have learned that intentionally connecting new nurses to successful and seasoned nurse leaders helps them feel less isolated and provides them with guidance on how to seek assistance when they need it. Complex Units Require Complex Critical Decision-Making New nurses today often work in specialty settings with complex patients whose care requires high-level decision-making skills. At the time they entered the NNLI, the new nurses in this study were all practicing for 12 months or less, with a mean of 6 months. Of the 81 nurses who contributed to the focus group data, 77% (n = 62) were employed by and practiced in units that are considered specialty areas. Their descriptions of a typical workday indicate that they are involved with multiple demanding patient situations that require high-level critical clinical judgment on a regular basis. One nurse described her day: “Sometimes you have three people dying at the same time. That’s just the way it is. And you need to deal with it all day long. Just accept it. Work with it . . . .” 408 Many of the nurses reported that they had been in situations in which they were expected to make important decisions regarding patient care quickly and did not have the opportunity to think through the decision. One nurse remarked: “You’ve got to keep going. There is no time to stand still and use your brain.” Another new nurse shared: “It’s hard because you are running around all night and the people are so sick and you don’t even get to stop and think through what you have done.” These complicated environments require critical thinking and clear judgment to support safe and quality care, yet opportunities for reflection on practice are rare. New graduates often feel unprepared or unable to meet these challenges. Recommendation: Extended Transition Support for Specialty Units. Historically, new graduates were initially assigned to general medical-surgical units. Today, for a variety of reasons, new graduates are often selected for positions in high-acuity specialty areas. Organizations typically provide extensive specialty education related to technology and disease management. In addition to this specialty orientation training, the study participants described a need for transition support that includes opportunities to process emotionally the intense patient situations encountered in these units. New graduates need periodic professional evaluations to ensure emotional acclimation to the intensity of the practice environment. This transition support is needed well beyond the first year. As one new nurse stated: “So pushing the baby birds out of the nest to see if they’ll fly isn’t the best plan for ensuring competent and safe care.” To promote quality care and competent outcomes, Tobin (2007) advocated for a clear collaborative partnership among continuing education, practice units, and new nurses entering those areas. Contradictory Information New nurses have many questions when they enter practice and often seek the advice of other professionals. They reported in the focus groups many instances when they received contradictory information from colleagues. One participant expressed her desire for more clarity in the guidance she was given: “I have a lot of questions and I like to be able to sit with someone and answer those questions, not get everyone’s opinion and then be more confused than ever.” Another commented: “There are so many questions and concerns as well as guidance that I am still looking for, and I seem to be given the wrong answers by some of my staff.” Given the pace of some clinical environments, new nurses are expected to make clinical decisions quickly, yet they find this difficult when there The Journal of Continuing Education in Nursing · September 2009 · Vol 40, No 9 are conflicting viewpoints from colleagues. They also reported that organizational policies and procedures on which they rely for guidance were not always accessible quickly. Recommendation: Consistent Preceptors Who Focus on the Positive. Through the eyes of new graduates, assigning the new nurse to one individual and “their schedule” improves the consistency of the preceptor experience. Having one preceptor reduces the frustration that new graduates feel as they sift through contradictory information and attempt to learn organizational policies and procedures. The encouragement received from preceptors was highly valued by new graduates. In the midst of the challenges expressed by the new nurses, there were many heartening comments, stories of accomplishments, and reports of professional validation from preceptors. The new nurses recognized moments of professional caring and relished reflecting with their preceptors on the transformative experiences within their nursing practice (Boykin & Schoenhofer, 1991; Newman, 2008). These positive experiences should be shared and celebrated with preceptors and staff within organizations. key points Implications for Nurse Educators in the Practice Setting Ten percent of the current nurse work force employed in acute care settings is made up of new graduates (Berkow, Virkstis, Stewart, & Conway, 2009). The successful transition of these novices into practice is a critical issue for the profession in today’s chaotic health care environment. Nurse educators in practice settings play a key role in designing programs that support new graduate nurses in practice. The findings over the last 2 years with novice nurses suggest that there is a strong need for the content included in the NNLI program (Sidebar 1). The current study also confirms the importance of the essential topics established for the transition modules, which are included in the evidence-based regulatory model for new nurse practice proposed by the National Council of State Boards of Nursing (Sidebar 4). In addition to curriculum content, research supports a need for nurse educators and leaders to advocate for consistent preceptors and extended orientations for new graduates. Opportunities for new graduates to meet with each other and nurse leaders in their organizations are especially important in the first year of practice. The enthusiasm generated during conversations in the NNLI sessions was contagious. A determined effort to focus new nurses on the positive aspects of the nursing profession can successfully extinguish a great deal of the negativity that new graduates often feel, and can promote a smoother transition into practice. References New Graduate Nurses Dyess, S. M., Sherman, R. O. (2009). The First Year of Practice: New Graduate Nurses’ Transition and Learning Needs. 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Development of a post-basic critical care program for registered nurses: A collaborative venture between education and practice. The Journal of Continuing Education in Nursing, 38(6), 258-261. Williams, C. A., Goode, C. J., Krsek, C., Bednash, G. D., & Lynn, M. R. (2007). Postbaccalaureate nurse residency 1-year outcomes. Journal of Nursing Administration, 37(7/8), 357-365. The Journal of Continuing Education in Nursing · September 2009 · Vol 40, No 9 TR A N SITIO N TO PRACTICE By Crystal Wilkinson, DNP, RN, CNS-CH, CPHQ Associate Professor o f...
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