Preparing nursing students for transition to professional practice
This publication reports on the strategies of self-support emerging from interviews with graduate
nurses. Transformational strategies which mitigated the inconsistent support were typically
experienced. These strategies were assembled into the ‘ways of being’ self-support model for
the purpose of empowerment of undergraduates, thus enabling them to navigate the transition
from nursing student to professional nurse. My contribution to publication 4 as corresponding
author is detailed below. (An authorship declaration is provided in Appendix 5).
Citation
Mellor, P.D. & Gregoric, C. (2016). Ways of being: Preparing nursing students for transition
to professional practice. Journal of Continuing Education in Nursing, 47(7), 330-340.
[10.3928/00220124-20160616-10]
Journal impact factor: 0.74 Citations: 35 (See Appendix 4 for details)
Authorship statement and publication background
This study is informed by publication three, ‘Strategies new graduate nurses require to care and
advocate for themselves: A literature review’ (Mellor, Gregoric & Gillham 2017), which assisted
with framing the questions used in the interviews with graduate nurses for this study. It also
allowed an informed application for support of an establishment grant which was approved on 23
January 2013. I applied for ethics approval initially with the Flinders University Social and
Behavioural Ethics Committee (SBREC); however, due to the perceived clinical focus, I was
redirected to the Southern Adelaide Clinical Human Research Ethics Committee (SACHREC). In
addition, I had to address the requirement for Low and Negligible Risk (LNR) specific to each
health unit, as some clients may have had special needs. My application was successful, and
due to the reflexive nature of the research, included a number of reviews and extensions as
appropriate. Site specific approval was appropriated for the three selected health units, i.e., 2
metropolitan teaching hospitals (5 informants) and 1 rural health service (4 Informants). Various
adjustments and extensions were granted until 21 June 2015. The following example is
representative of SACHREC Ethics Committee permissions for one health unit:
• Use of SA Health email accounts
• Approval of flyer content and contact details
• Leave flyers out for collection by those interested at the RN TPPP Graduation Ceremony
in March
• Place flyers in the graduate nurse pigeon holes in the casual pool office for those who
have joined the casual pool
Research design
I selected, developed, and wrote up the research design. Grounded Theory Method was used, as
the development of new theory was a primary goal of the research. Further detailed discussion of
the methodology/methods has been provided in Chapter 1. The method of data collection was via
interviews with graduate nurses, and I developed and provided the questions used for the
interviews. Throughout the research process, I consulted with Professor Jennene Greenhill and
Associate Professor David Gillham (via videoconference as required) who provided practical
suggestions for the ethics application requirements and for gaining access to the health units.
Data collection and analysis: I engaged Lucy Atkinson (research assistant and experienced
interviewer) to undertake some of the interviews. To provide credibility and to contextualise/ check
the interview questions, we were both present for the first interview. A professional transcription
service was also engaged to provide a written verbatim account of the recorded interviews for the
purpose of analysis. All care was undertaken to facilitate the ethics of interviewing informants with
regards to freedom of choice, avoidance of coercion, appropriate consent, and maintenance of a
professional and confidential service. We interviewed five graduate nurses from two selected
metropolitan hospitals and four graduate nurses from rural health services. The goal was to
interview a minimum of twelve graduate nurses. However, there were ongoing challenges due to
the strict ethics requirements and the reluctance of some organisations to allow access. Even
where access was permitted, there were many restrictions and few willing informants. In order to
mitigate these obstacles, a research partnership was forged with the transition to practice
coordinator of a major hospital. A reciprocal arrangement, including sharing of the data, was
implemented. Approval of this arrangement with SACHREC was successful and produced three
willing informants. While not optimal, this provided an acceptable overall number of nine recorded
interviews.
Due to a change in my work location, I was fortunate to engage Dr. Carolyn Gregoric as research
associate to assist with processing of the transcribed interviews using QSR NVivo 11. This proved to
be a valuable resource. Following immersion of myself in the data, and through the process of
theoretical sensitivity (in a graduate nurse context), there emerged multiple socio-emotional qualities or
‘ways of being’. As a result, “ways of being” for the nursing context emerged.
Writing and editing: I was the corresponding author and wrote the initial manuscript. This included the
quotations selected (from the interview transcripts) for the purpose of illustrating each element of the
“ways of being” theoretical framework. I also populated the “ways of being” concept model and
allocation of strategies appropriate to each concept, i.e., ways of feeling, ways of doing, and ways of
relating. My other contributions included the design of figures/tables and manuscript revisions when
responding to reviewers. Dr. Carolyn Gregoric as first co-author, offered feedback at each stage
of development providing valuable perspectives with regard to inclusions, conciseness, and
clarity. Dr. Gregoric also assisted with additional important and contemporary resources relevant
to grounded theory (i.e., Charmaz, 2014). An authorship declaration is included in Appendix 5. A
complete version of this publication is included on the following pages.
Ways of being: Preparing nursing students for transition to
professional practice
Abstract
Background: The new graduate registered nurse (NGRN) does not work in isolation but within
an organizational environment. Unfortunately for the NGRN, transition to practice programs are
often variable and under resourced which means that promised support is unlikely to eventuate.
Many NGRNs learn the skills required to navigate the nursing culture “on the job” without support
and by trial and error.
Method: A grounded theory method was used to identify the strategies used by nine NGRNs
to thrive during their transition to professional practice.
Results: Ways of being emerged from the data to explain the social and emotional strategies
NGRNs use during the first year of practice. The Ways of Being model includes ways of
feeling, ways of relating and ways of doing.
Conclusion: University preparation needs to ensure that the NGRN is provided with the skills to
successfully navigate the workplace. Use of the Ways of Being model could help achieve this.
Keywords: new graduate nurse; self-care; self-advocacy; transition to practice; novice;
coping strategies; self-efficacy; resilience; hardiness; empowerment; ways of being.
Introduction
Internationally, the approach to transition to professional practice for the new graduate registered
nurse (NGRN) has been to provide a specialised program for this purpose upon entering the work
force (Whitehead, Owen, Holmes, Beddingham, Simmons & Henshaw et al., 2013). The NGRN
therefore expects that they will be welcomed and need little personal preparation for the transition
other than the knowledge and skills learnt at university. This knowledge traditionally focuses
exclusively on patients/clients and not on NGRNs as individuals. Unfortunately, for the NGRN,
promised support is not always provided in graduate nurse transition programs (Howard–Brown &
McKinley, 2014; Whitehead et al., 2013). As a consequence it is not uncommon for the NGRN to
fend for themselves when confronted with a challenging work environment during their transition
to professional practice (Berry, Gillespie, Gates, & Schafer, 2012; Chandler, 2012; Clark &
Springer, 2012; Feng & Tsai, 2012; Hart, Brennan & de Chesnay, 2012; Laschinger & Grau,
2012; Parker, Giles, Lantry & McMillan, 2014; Thomas, Bertram & Allen, 2012).
Many NGRNs are frustrated by the lack of support and being left alone without the strategies to thrive
(Parker, Giles, Lantry & McMillan, 2014). Successful NGRNs have related that many of the supports
implemented were self-initiated (Mellor, 2009). At the moment, health care is portrayed as perfect and
that transition programs are perfect and the health system is perfect. The discrepancy between
preparation and the realities of practice was first identified by Kramer (1974) and termed reality
shock. It has also been found that the hospital culture is much more of a challenge than technical
knowledge and clinical skills to navigate (Duchscher, 2009; Halfer & Graf, 2006). Hence,
preparation of the NGRN as an individual, with regard to the relevant resilience strategies
necessary to provide self-support, is critical during the transition to professional practice. Previous
research suggests that these skills primarily involve negotiating the nursing culture. For instance,
Crigger & Meek (2007) found that many NGRNs may be driven by shame to avoid revealing that
they do not know something in their early clinical placements and hence compromise patient care
by not asking for help.
From previous studies it is known that there are important conversations that still need to be had
by nurse teachers with nursing students to ensure the NGRN thrives through empowerment,
engagement and relevance of the education process. NGRNs often do not have opportunities to
discuss the concept of moral distress and how to address conflict between the care they have
been taught and that which they are being pressured to perform (Day & Rickard, 2012; Gallagher,
2010). NGRNs need to respond appropriately to an experienced registered nurse (RN) whom, for
example, when consulted about the need to call the medical emergency team directs the NGRN
to alter the record so it is in a positive range and the team is not called (Purling & King, 2012). The
NGRN may not have had a performance review for an extended period (Goodwin-Esola, Deely &
Powell, 2009) and needs to know how, in these circumstances, to obtain timely feedback or be
cognizant of how to self-monitor if their request is not forthcoming. This may include looking for
the positive and recording incidents to provide evidence of successes to shift their emotions and
self-image.
The main aims of this study were to further develop a body of knowledge surrounding the
capacity for NGRNs to take an active role in the process of transition rather than being
bystanders and reacting to the scenarios that present on a daily basis. Recommendations are
made which will assist universities to better prepare NGRNs to take control and become
professionals and leaders who can objectively experience the transition and learn from it.
Research Method
This is a qualitative study that uses grounded theory to identify the strategies used by NGRNs
to thrive during their transition to professional practice. Grounded theory originated and was first
articulated by Glaser and Strauss (1967). Grounded theory involves viewing the research data
obtained as the basis for generating new theoretical constructs (Glaser et al., 1967). However,
where it is found that recognized theory fits the data with minimal distortion then verification or
extension is a possible outcome (Glaser et al., 1967; Strauss & Corbin,1990).
Study rigor was provided using the four criteria of Guba and Lincoln (1989) i.e. credibility,
transferability, dependability and confirmability. To provide credibility, predetermined closed
questions were used to collect informant data and open-ended questions were used to elicit
richness of ideas, feelings and strategies. Interviews were transcribed verbatim. To assist
transferability, field notes were taken to supplement richness of the data and provide context
(Charmaz, 2014). An audit trail is available for confirmability (Guba et al.,1989). Transferability
is reflected in the rich description of the situated context of the nine informants and the diversity
of their transition experience. To provide reflexivity interviews were shared between the primary
researcher, who is a university lecturer and an experienced interviewer who was about to
undertake her transition to professional practice as a NGRN. The first interview was conducted
with both interviewers present in order to contextualise the questions to be asked and to provide
confirmability (Guba et al.,1989).
Ethics approval was gained from the Southern Adelaide Clinical Human Research Ethics
committee, and site specific approval was gained from all participating health units. Informants
were provided with a letter of introduction, an overview of the nature of the research being
conducted and a description of their role. Consent forms and the list of questions were provided
to informants so that opportunity was provided for consultation with colleagues, friends or family.
Informants were also informed at interview that participation was voluntary; they could withdraw at
any time and decline to answer any question.
Table 1. Characteristics of study participants
Under-
Prior Non-
Practical
Hospital
graduate BN
baccalaureate Nurse in
Graduate
Location Areas of Practice
Hours
Age
Program at Practical
the Same Nurse Rural/City/ During Graduate
per
Range Flinders Nursing
Institution Transition Public/ No. of
Nurse transition
Week
Informant* (y) Family University
Qualifications as GNTP
Program
beds
Program
(Shifts)
Caroline 40-50
Yes Yes Yes
No
Yes
Rural public
Aged care; general
32
(30-60 )
medical surgical;
emergency
Alison 40-50
Yes Yes
No
No
Yes
Rural public General medical
32
(30-60 )
surgical ; renal;
chemotherapy
Jenny 20-30
No
No
Yes
No
Yes
City public
General medical;
32
(300 – 499)
day surgery
Leslie 40-50
Yes Yes
No
No
Yes
Rural public Operating room;
32
(30-60 ) general medical
surgical;
emergency
Natasha 30 -40
Yes
No
Yes Yes Yes
Rural public
General
32
(30-60)
medical/surgical;
operating room
Heather 40-50
Yes
No
Yes Yes Yes
City public
ICU; medical ward
24-32
(300 – 499)
Sandra 20-30
No
Yes
No
No
Yes
City public
Neurology/CVA;
32
(500 – 700)
neonatal
Rachel 40-50
No
No
No
No
Yes
City public
Hematology ;ICU
32
(500 – 700)
John 40-50
No
Yes
No
No
Yes
City public
Cardiac; recovery
32
(500 – 700)
Note. BN = bachelor of nursing; GNTP = graduate nurse transition program; ICU = intensive care unit; CVA = cerebrovascular accident
*Pseudonyms have been used.
Nine informants volunteered to participate throughout rural and metropolitan South
Australia. Informants were those who had recently completed their transition to professional
practice program. See Table 1 for a more detailed account of each informant and their
situated context. Pseudonyms have been used.
Interviews with informants were undertaken at a time and place convenient to the informants
and away from the work environment where possible. Interview duration was 45 to 90 minutes.
Interviews were undertaken face to face or, where this was not convenient for the informant,
via telephone. All interviews were digitally recorded,with consent, on a voice recorder. An
interview guide included closed and open ended questions such as:
• How has your role changed from student to registered nurse? (Prompts: How different
do you feel? What are the skills that you have acquired? What are the barriers to your
learning?)
• Did you feel you were well prepared for the RN role? If not, why? If yes, Why?
• What does the term “resilience” bring to mind? (Prompts: This elicits the person’s
own language)
• Tell me about the challenges you have experienced as a new graduate (Prompts:
e.g. fitting in, time management, maintaining ideals, ethics)?
• What strategies did you use to help cope with these challenges (Prompts: e.g. role
models, preceptors, mentors, friends, family or other creative strategies)
•Why do you think these strategies helped you?
Findings and Discussion
Following immersion in the data and the process of theoretical sensitivity (Strauss et al., 1990),
multiple ways of being, all of them socio-emotional in nature, emerged as the overarching
theme. (Figure 1)
Consideration was given to developing a model specific to these results, however a search of the
literature using the key words ways of being revealed a pre-existing social and emotional learning
model called Ways of Being which had been developed by Blyth, Olson and Walker (2015).
Because this model clearly represented the emerging themes, it was then applied to the
study’s findings. The model is complimentary and a good fit. Indeed, Blyth et al. (2015)
encourage practitioners to map skills onto the theoretical model as a means to increase
awareness and understanding about effective social and emotional supports for their
learners.
The holistic concentric circular Ways of Being model (Blyth et al., 2015) represents identity,
awareness and navigation in feelings, relating and doing. There are six key aspects of the
model: ways of feeling, ways of relating, ways of doing, ways I am, ways I am aware and ways I
navigate. These six nonlinear key aspects include relevant skills, experiences, capacities,
attitudes and beliefs for social and emotional wellbeing (Table 2).
Table 2. Ways of being model: six key aspects and definitions
Although developed initially with a youth focus, the Ways of Being model (Blyth et al., 2015)
nonetheless provides a powerful framework for comprehensive consideration of the strategies
required to succeed in the culture of nursing. Social and emotional competence is increasingly
being recognized as important for success in any field (Mooney, 2007; OECD, 2015;
Weissbourd, Bouffard & Jones, 2013). These competencies currently exist in a number of
disparate ways such as social intelligence (Walker & Campbell, 2013), emotional intelligence
(Mayer & Salovey, 1993; Johns Hopkins University, n.d.), mindfulness (Ponte & Koppel, 2015),
grit (Duckworth & Gross, 2014; Robertson-Kraft & Duckworth, 2014) and resilience (McAllister &
Lowe, 2011). The Ways of Being model (Blyth et al., 2015) unifies these. The increased
emphasis on social-emotional skills is imperative as they are now considered more important by
employers than technical skills (OECD, 2015). Social and emotional capital is not only valuable
for success when making the transition from student to RN but also their quality of life
academically, at work and in one’s personal life (Beland, 2007).
Figure 2 maps strategies used by NGRN informants according to the Ways of Being model
(Blyth et al., 2015). Firstly, within the social and emotional dimensions, are ways of feeling,
ways of relating and ways of doing. Secondly, within the sub- layers are ways I am aware and
ways I navigate. At the center of the model is the development of identity expressed as ways I
am. Identity is considered most significant and purported to influence social and emotional
development at all levels (Blyth et al., 2015).
The strategies for success as identified by NGRNs are discussed in more detail below using the
six key aspects of the Ways of Being model adapted from Blyth et al. (2015). However, before
doing so it is important to note that the strategies used by NGRNs interviewed for this study
developed over a relatively short time and resulted from trial and error. Their initial responses to
events during their first few months may have been reactive. However, by being proactive and
persistent, the NGRNs developed resilience. Along the way they may have sought professional
assistance, for example, Heather, from a city hospital, found herself in a negative work
environment and sought assistance through the Employee Assistance Program. After doing so
she changed her approach to navigating the nurse/doctor relationship on occasions where she
does not understand the rationale for a medical decision.
Question the doctor that’s what I do, “Why are you doing that?” and my line is and which
I've noticed at my hospital is “look I'm the nurse looking after this patient and I know that
you're the doctor but nurses and doctors think differently so explain to me your reasoning
of why you're doing it that way because next time I'll learn and I'll be able to pick that up
for next time”. So it’s not coming back on them, it's coming back on you, as you want to
improve your knowledge. (Heather)
In this way the NGRN retains respectful and productive relationships. The NGRN now has clarified
the rationale and understands the overall goals of care more effectively. As a result many other
nursing activities can be provided, such as patient education, in an informed and appropriate
way. NGRNs who can navigate their emotions and relationships achieve the best outcome for
patients/clients (Kaufman & McGaughan, 2013).
Ways of feeling
The NGRNs readily described their feelings and tried to understand their own emotions when
prioritizing care. Self-management strategies included letting go of not being able to do everything.
These understandings require emotional competence and self-regulation. For example, Alison
described how she created a mindful space to purposively stop irrational thoughts:
So you’ve got a screaming brain going on, you're freaking out, you know more haste is
less speed basically, you just stop and think “Right what's my priorities here, I need to
give these antibiotics and they need to be timely. Right we’re going to get all them done”.
Next, you can worry about bed making, changing sheets, you know, those other little bits
and pieces that you can prioritise and, you know, a bit further down the track.
Emotional competence can be achieved by replacing anxiety with more productive thoughts, as
Leslie commented:
So, I think that it became a good coping strategy to have something else to focus on, like
the next day or the next patient interaction, or whatever to get it out of my head – so, I’d
push all that anxiety and repetition out by replacing it with something else that was
productive. (Leslie)
The self-management strategy of reflection enables objectification of the experience of being a
NGRN. As Rachel recounted:
And being honest with your reflection on yourself and the situation that you’re in. I know I
gave myself a lot of – I am only new – I can’t be expected to know everything because I
am only new to this role, and nobody should expect me to know anything more than a
new RN. That’s why I’ve got new written all over me.
It is important that NGRNs are able to recognize their ways of feeling and the impact on patient
care. The findings of this study demonstrate that NGRNs adopt strategies to make sense of their
emotions in order to provide effective and timely care to their patients (Jones, King & Wilson,
2009). To achieve this degree of emotional regulation is essential to nursing practice (Bulmer-
Smith, Johns Hopkins University, n.d; Profetto-McGrath & Cummings, 2009). This requires
being mindful of the irrational or overwhelming feelings and choosing to stop and reconstruct
this feeling state in a more positive and objective way. Emotional intelligence can affect decision
making and is considered more important than IQ with regard to future success (Yale Center for
Emotional Intelligence, 2013). The skills to endure hardship, the skills of emotional intelligence
and managing conflict are all strategies that assist NGRNs (Hart et al., 2012). According to
Freshwater and Stickley (2004), emotional intelligence should be central to learning to care for
oneself and others. Freshwater and Stickley (2004) strongly advocated that the value and
development of emotions be included as a priority in the nursing curriculum in order to produce
emotionally intelligent practitioners.
Ways of relating
For NGRNs, interactions and relationships with others did not always go as well as they would
like. They are still learning to navigate their interactions with others and develop relationships.
The predominant strategy NGRNs used was to constantly be mindful of others perceptions.
They adopted the role of sensitive negotiator and protector of their nursing colleague’s self-
esteem. This heightened sensitivity of some health care team members to being questioned
about any aspect of patient care required the NGRN to take a tactful, non-threatening and
gentle approach; if the answer is not obtained from one person then they sought it from others,
but the message was to do so discretely (Boychuk Duchscher, 2012).
As Caroline vocalized, there are many strategies for interacting with other members of the
nursing team:
It depends on the person themselves and I ask lots of questions as some people can find
that intimidating even though you are doing it just for your own knowledge base and
trying to develop rationales for things, but for some people it may be their personality or
they have been in an environment for a certain amount of time and if someone new
comes asking questions…it challenges them…even though you are not criticizing them
you are just trying to say well what is your understanding of the situation.
Empathy for the experienced staff members and awareness of the possible effect of asking
questions on their levels of comfort is important. The nurse who is intuitive of others
perspective and mindfully takes this into consideration better navigates their work
relationships. Asking questions in a positive way and being keen to learn can also develop
connectedness and build warm relationships with other staff members.
I sort of went in and was open and asked questions and I think when you have that sort of
attitude that you’re really keen to learn…and I think you find people want to open up and talk to
you and tell you what they do, and once you start doing that you sort of warm to that
relationship. (Natasha)
During the process of professional socialisation NGRNs are extremely sensitive to the gaze of
others and strive for connectedness (Malouf & West, 2011). Feng et al. (2012) also
acknowledge the concerns that NGRNs have with “fitting in” and the potential influences on
their behaviour. Provision of care and attention to relationships was considered an essential
part of social/ relationship management (Kooker, Shoultz & Codier, 2007). Successful NGRNs
assert that it is important they stay true to their beliefs, are comfortable with their own practice
and are aware of the cultural influences and relationship dynamics on their practice.
Ways of doing
The NGRNs approached tasks and goals with a willingness to succeed despite the circumstances
they found themselves in. The nurses integrated cognitive factors together with ways of
feeling.They demonstrated tenacity and responsible decision-making rather than basing their
decisions on their feelings of inadequacy or avoidance of shame. Their strategy is more clearly
focused on outcomes for the patient/client rather than concerns for how others might perceive
them and their practice. This requires moral courage (Lasala & Bjarnason, 2010). As three
informants observed:
Just don’t be scared to ask. If there is anything you want out of your program or if
there is anything you need on the floor for the shift – just yell out and just ask and
sometimes you will get a negative response but I think don’t let that deter you – just
keep going and keep asking and someone will assist. (Natasha)
Deal with what you need to deal with and the other stuff it will come when it comes and
don’t be afraid to go “You know what! I've got 6 doubles at the moment there's no way I'm
going to be able to do this with me and my enrolled nurse [practical nurse or whoever
you're with], you need to give me a hand.” Don’t be afraid to ask for help. (Heather)
I'm not scared to ask for help anymore, if I need help – that’s like when they have the
board handover and they're like what zone are you in, I'm not scared to say I'm in
orange, if I'm in orange and it's going to affect my patient, the sort of level of care they
get, I'm going to say so, but when you're a new graduate registered nurse you feel like
you’ve constantly got something to prove, you feel like if you say you need help you
mustn’t be doing your job properly. (Sandra)
Rather than being afraid or ashamed to ask for help the NGRNs recommend the strategy of
being proactive and persistence. Not worrying about getting everything done and focusing on
the important things, or getting things done with the assistance of others was an important time
management strategy (Malouf et al, 2011). The focus on achieving safe outcomes for the client
is reported as less stressful and assists with prioritization.
Ways I am
It takes time for the NGRN to develop a sense of identity (Hamilton, 2005) as the informants of
this study confirm. Initially during the transition to professional practice the NGRNs felt they had
limited control over their working life. As they became more experienced they developed a
greater sense of agency and were more positive about the future. For example, when Leslie
was under siege from patients and staff she felt little sense of control. She then decided to take
back her sense of self with a renewed mindset.
And around the same time I had a couple of rude patients that were just hard to deal with.
They would just say things rudely to me, like I was their slave, order me around. And I
heard someone respond to a patient one day, and I went, ‘Oh I can do that.’ And the next
time a patient said something rude to me, I said, ‘you don’t need to speak to me like that,
you’re allowed to ask in a nice way,’ and I didn’t acknowledge it and let myself get walked
over…I took a lot of power back just by learning a couple of little sentences and ways of
speaking to people without being angry but being assertive. (Leslie)
After hearing how other people stand up for themselves, and then by modelling and doing the
exact same thing herself, the NGRN can obtain the power to not let patients dictate and not let
other staff take advantage. They can develop a greater sense of agency. In the following
excerpt a different form of personal agency is demonstrated: In terms of shift work, it's quite hard to
get used to at first, but you've just got to make sure you have a decent work, life balance which is quite
hard being a nurse. Your sleep is important even though a lot of people think, ‘Oh! I can go to work on 4
hours sleep’ …if you make a medication error then your registration can be on the line. So I think people
keeping up their health and sleep is important. (Jenny)
Maintaining a healthy body through healthy eating, exercise and rest can strategically assist
NGRNs with maintaining a sense of control over emotions and mental state. Another method
mentioned is to observe good role models, how they interact and maintain their effectiveness
both personally and professionally. Nurses who have a sense of agency, believe they are
effective and imagine their own success are more likely to feel empowered (Simoni, Larrabee,
Birkhimer, Mott & Gladden, 2004). The strategy of creating positive interpretations from
previously unhelpful thinking assists with development of self-efficacy (Laschinger et al., 2012).
Ways I am aware
The NGRNs were aware that they had a lot to learn and that others on the medical team could
help them develop competency. Successful NGRN’s are intuitively aware of other people’s
responses to reactive behavior such as anger. Through humility they can create a cooperative
and reciprocal relationship with other staff members. Dean exemplifies this:
You need to be really humble and not angry because then people react very strongly to
anger, so be completely so. I think we really need to make an effort as new [graduate]
nurses to offer our help or really just enquire…it means to go around and just talk to
nurses and remember what they like... it really gives you a different dimension in the
relationship…I might help them, and that really helps because those are the same
nurses that come back later, when you ask for help they are happy to give it to you.
(Dean)
Self-awareness requires social intelligence (Goleman & Boyatzis, 2008). Nursing care is
performed within a social context and requires good relationships among professionals. Malouf
and West (2011) discuss the vital need that NGRNs have to “fit in” to their clinical situation.
Feng et al. (2012) also reported the importance of the NGRN being accepted by senior staff.
Walker and Campbell (2013) identified social intelligence as a critical work readiness factor.
This is further supported by Feng and Tsai (2012) with the assertion that NGRNs found
“learning how to solve the gap between knowing and practising was easier than learning how to
behave appropriately and to deal with people in the workplace” (p. 2068).
Ways I navigate
Initially, the NGRNs tended to navigate their emotions, work relationships and tasks alone. After
meeting with limited success they were more willing to open up to others and seek additional
support. It is possible to achieve excellent results with knowledge of the support networks
available and thereby avoid feeling overwhelmed (Mellor & Greenhill, 2014). Natasha did this:
I pulled on Adelaide services so basically rang through to MedStar [a rural medical retrieval
service] …if you’re ever in trouble there’s always someone else, so for me it was like tapping
into them and just explain the situation… I got a lovely man [Medstar staff member] and
he was quite willing to help, and he sort of walked me through it and he didn’t go off the
phone until I was comfortable and even helped with what medication I should be giving
and asked me to fax him through the ECG.… He represents the extent of that support
network – I
suppose just knowing that it’s very vast and you’re never alone – there’s always
someone out there that can help you. (Natasha)
Conflict resolution is part of navigating emotions and getting things done. For example, a
situation can be de-escalated when the NGRN actively listens to the doctor, provides an
understanding response and maintains a calm demeanour.
One doctor came in and one of the higher staff members had ruffled his feathers and
given him a real hard time, he come in, he was furious, absolutely furious. And I talked to
him, I said “It's okay, it's all getting sorted, I’ll go do that for you, don’t worry, it’s fine”. I
didn’t actually realise what the other person had done to ruffle his feathers, and yeah I
calmed him down and one of the midwives came up to me after and said “Just letting you
know you did really well in that discussion”. (Alison)
For the NGRN it is important to build social intelligence/psychological capital to assist in the
event that an incident might cause personal distress (Duchscher & Myrick, 2008; Taylor, 2012;
Walker et al., 2013). Effective communication between clinicians, other staff and students has
been identified as a strategy to decrease horizontal violence (Curtis, Bowen & Reid, 2007;
Douglas, 2014). Berry et al. (2012) found a negative effect with a significant correlation between
horizontal violence and negative work productivity of novice nurses.
Overall, this study found that to succeed the NGRN has to be extremely proactive and use
whatever skills and resources they can to gain the outcome they desire. Nobody can be relied
upon to lookout for the NGRN so every individual has to create their own environment of
support as illustrated in the Ways of Being model (adapted from Blyth et al., 2015). The
informant Caroline gives voice to the dynamic interactive nature of “ways of being”:
You have got to be proactive…I have made a huge push to get where I wanted to be…
you chase it…you try and create opportunities…it is not going to come to you…no one
else is going to know what you want to do… you have got to get it out there and plant
the seed...
you don’t have to be in a rut…nursing has so many pathways…you can just go in
different directions but…you have got to seek it...you can’t just sit there and complain
about it…I am definitely in my happy place now.
Limitations
In this study only nine NGRNs volunteered to be interviewed. Guest, Bunce and Johnson (2006)
in their study of interviews and qualitative research, found that themes and variability were often
present after only six interviews and saturation was common after twelve interviews. It was also
originally planned that all interviews would be face to face; however, a number of interviews
took place via telephone for convenience of the informants. In order to address this possible
variable, resources on telephone interviews were accessed (Wilson, Roe & Wright, 1998) and
data obtained was equally rich. Interviews took place during an 18 month period (Dec 2013 -Jun
2015) due to availability of informants and access to venues with regard to ethics requirements.
It is not likely that the health cultures would change significantly during this time but is a
consideration.
Age of participants also required consideration. While some informants were 20-30 years of
age, others were in their 50’s. The average age of participants was approximately 35 years.
Navigating the nursing culture necessarily requires individuals to develop tolerance of
uncertainty and to effectively moderate their stressful experiences (Boychuk Duchscher, 2012;
Duchscher, 2008). The focus of this research was to identify strategies that assist with
transition from student to NGRN. As such, the Ways of Being model (Blyth et al., 2015)
provides a template for self-assessment/identification of the desired socio-emotional skills in
accordance with the informant’s developmental stage and experience of previous stressors.
The life context in which informants were functioning is illustrated in Table 1.
Implications for Nursing Education
The resulting Ways of Being model could be used to inform topic development across the
undergraduate nursing curriculum. In addition, the model is also a self-assessment tool that can
assist nursing students in their preparation for transition. Having some fore knowledge of what
can be expected during transition to professional practice and the likely scenarios NGRNs face
on a personal level is critical for exiting nursing students. Throughout these interviews, clinical
skills were rarely mentioned as obstacles. However, being able to deal with the culture of
nursing was ever present. Schools of nursing need to recognize that social-emotional skills are
as important for university graduate’s preparedness to being a RN as clinical skills and
evidence based practice. There also needs to be more support to help lecturers and clinical
facilitators develop and create links between RN competencies and social and emotional skills
so that they are integrated throughout the curriculum.
Implications for Future Research
Further research needs to be undertaken with regard to the adoption of social-emotional
learning strategies, including the proposed Ways of Being model, as an intervention especially
in the final year prior to graduation. The relationship between social-emotional learning and
outcomes for NGRNs during their first year of practice should also be further investigated.
Partnerships with nursing educators and the health care industry would provide opportunities
for obtaining feedback and suggestions for improvements to the proposed Ways of Being
model (adapted from Blyth et al., 2015).
Conclusion
Throughout this study, NGRNs related the social and emotional strategies used to navigate the
culture of nursing. These strategies have been illustrated using the Ways of Being model (adapted
from Blyth et al, 2015). The results reinforce the complexity in the relationships between the nurse,
the patient/client and other practitioners. Recognizing this complexity is critical (Burger, Parker,
Cason, Hauck, Kaetzel & O’Nan et al, 2010; Ebright, 2010) and highly developed social and
emotional skills are required to navigate successfully (Kooker et al., 2007).
Organizational culture “is a complex mixture of different elements that influence the way things
are done, as well as the way things are understood, judged and valued” (Kaufman et al., 2013,
p. 52). As such, it must be recognized that the NGRN does not work in isolation but within an
organizational environment. Unfortunately, transition to practice programs are quite often
variable and most are under resourced which means that promised support is unlikely to
eventuate. As a result many NGRNs have to learn the skills required to navigate the nursing
culture “on the job” without support and by trial and error. By further developing skills for social
and emotional wellbeing, as suggested by the Ways of Being model (adapted from Blyth et al.,
2015), nursing educators can help improve this situation for future NGRs.
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