Psychological capital and self-efficacy
Psychological capital was an important consideration advanced by previous studies
(Boamah & Laschinger 2015; Kim & Yoo 2018; Laschinger et al. 2016). Psychological
capital is a concept consisting of self-efficacy, hope, optimism, and resilience. These
factors are known to influence attitudes towards work and levels of achievement (Kim &
Yoo 2018). Self-efficacy (or confidence) is the conviction that the graduate nurse has
the capacity to successfully mobilise the resources needed to achieve a specific
outcome within a given set of circumstances (Boamah & Laschinger 2015; Kim & Yoo
2018). Hope refers to the graduate nurse’s levels of enthusiasm and commitment to
achieving their goals. Hope involves being both persistent and strategic in the face of
adversity (Boamah & Laschinger 2015; Kim & Yoo 2018). Optimism is about the
attribution of success in the present and in the future. Positive events are attributed to
individual, prevailing, or enduring phenomena and negative events as a consequence of
extraneous, non-permanent, and problem-specific phenomena (Boamah & Laschinger
2015; Kim & Yoo 2018). Resilience is the ability of the graduate nurse to recover from
hardship, adversity, or significant sources of stress (Boamah & Laschinger 2015; Kim &
Yoo 2018). These personal resources were considered more important for graduate
nurses than empowerment through adjustment of workplace structures (Boamah &
Laschinger 2015; Wahab 2017). A product of psychological capital is work engagement.
Work engagement refers to a high level of dedication, enthusiasm, and meaning in
which the graduate nurse is completely absorbed. Graduate nurses with an activated
work engagement focus on their patients rather than on concerns about the obstacles
faced in order to provide that care (Kim & Yoo 2018). The obstacles just add to the
intrigue and pose another challenge or puzzle which they are confident they will
overcome (Boamah & Laschinger 2015; Kim & Yoo 2018).
Boamah and Laschinger (2015) revisited earlier survey data collected from graduate
nurses (n=205) in a 2012 study. The aim of revisiting the research was to test the link
between perceptions of workplace empowerment, psychological capital, and workplace
engagement. The study was well constructed with quality measures used to validate the
questionnaires. The informants were located by accessing the registry list of nurses in
Ontario, Canada. It was
discovered that both psychological capital and workplace empowerment were significant
independent predictors of work engagement”. The researchers asserted that such an
environment is realised when workplaces keep graduate nurses informed, and provide
access to professional development opportunities and access to organisational
resources, enabling them to have a positive work experience.
The effect of environment was reinforced by Charette et al. (2019) who undertook an
ethnographic study of the factors influencing the practice of graduate nurses. A
purposive cross-section of staff members, including graduate nurses (n=4), nurse
preceptors (n=2), clinical nurse specialists (n=9), and nurse managers (n=4) were
recruited for the study. The researchers discovered that the workplace environment has
a significant influence on the competency, preparedness, and self-efficacy of graduate
nurses.
Self-efficacy was also found to be present in graduate nurses who were strategic in
their approach as an undergraduate nursing student, with some proactively seeking the
experiences required in order to succeed in their transition year. A reflection of this
choice might be researching further information about a procedure, or requesting a
change of venue for their clinical placements in order to hone specific clinical skills, i.e.,
the opportunity to debrief and process the dying experience (Charette et al. 2019;
Cadavero et al. 2020). Unfortunately, it was discovered that many nursing students
lacked self-efficacy traits and did not take advantage of their clinical placement
opportunities, i.e., they were passive in their approach to learning. As a result, they
were unprepared, and at a distinct disadvantage, compared to those who were more
self-directed. It was asserted by Charette et al. (2019) that Nurse Managers valued
such resourcefulness, including well-developed collaborative skills and overall
leadership qualities. Confidence and the ability to speak easily with all members of the
inter-professional team was highly valued, despite graduate nurses’ experience being
minimal and their clinical skills rudimentary (Charette et al. 2019; Feltrin et al. 2019).
Being transparent and able to speak up and ask for help was considered vital for patient
wellbeing and the safety of colleagues (Law & Chan 2015; Wahab et al. 2017; Feltrin et
al. 2019). Transparency was considered to be important to foster trust, instead of
adopting a pretence likely to be perceived as inauthentic. This act of being open with
colleagues and seniors was considered by some graduate nurses to be an essential
element of fostering the respect and engagement essential to “fit in” to the ward culture
(Feltrin et al. 2019). Not interpreting the actions of others as a personal affront was also
considered important, for a display of frustration by a co-worker may be related to
something else happening in their lives rather than to the graduate nurse (Feltrin et al.
2019).
Overall, there was much complexity to fitting in, and graduate nurses adopted a number
of diverse survival strategies. One strategy was to ensure there was a healthy
separation between their work and home life, which enabled the graduate nurse to
project a positive and professional image when interacting in the ward culture (Feltrin et
al. 2019). Many decided to adapt to the ward culture by changing themselves and their
personal style to align with that of their colleagues by adopting hybrid procedures and
practices to gain approval. Unfortunately, some of those practices were not evidence-
based (Feltrin et al. 2019).
The participants said that nurses including graduate nurses who stand out, by trying to
have or keep a more scientific approach to care and to base their practice on evidence,
can sometimes be left out by colleagues. This can limit the deployment of
competencies of graduate nurses, because to be accepted by their colleagues, some
graduate nurses will do anything to blend into the group. Others challenged
themselves to go beyond the expectations of their colleagues in order to be regarded
as self-sacrificing and a good nurse (Charette et al. 2019, p. 3626).
However, for some graduate nurses, the perceived necessity of fitting in and proving
themselves, meant there was also potential for self-neglect and exploitation. While
proving themselves “worthy” as a nurse had the likely benefit of an offer of a position as
a permanent staff member, it made them especially vulnerable. This vulnerability was
exploited by predatory nurse managers, and the graduate nurse was an easy target,
i.e., expectation they will agree to more overtime and be constantly available for extra
shifts. As a consequence, the negative impact on self-care with regard to their
relationships, the risks to their own health, and ultimately, to patient safety was quite
adverse (Oneal et al. 2019). Optimism, as previously defined, is associated with having
a positive view of the future based on attributes which are realistic and achievable in the
longer term (Boamah & Laschinger 2015; Kim & Yoo 2018). There were definitely skills
to be learned by the act of persisting through hardship, and some graduate nurses
positively reinterpreted the situated context of their transition experience in order to
succeed (Wahab et al. 2017; Boamah & Laschinger 2015). In one example, a graduate
nurse compared the gravity of her situation with the horror of victims who suffered
atrocities in war. This perspective gave her resilience to persevere, i.e., Mr. Jones being
late for his shower didn’t seem too much of a disaster. Furthermore, Wahab et al.
(2017) described four major themes emerging from their study, with each having a focus
on the development of resilience through the ability to recover from hardship or
adversity or significant sources of stress (Boamah & Laschinger 2015; Kim & Yoo
2018). The first of these attributes was to persevere and overcome obstacles through
not accepting failure as an option, i.e., perseverance and efforts to succeed were
enhanced by internalising the professional nursing role, embracing their spirituality, and
through firm adherence to moral obligation. The remaining themes were to accept one’s
responsibilities as an ordained nurse and fulfil the contract implied by their calling; be
adaptable to unfamiliar situations; and finally, to take control of one’s own learning
(Wahab et al. 2017). In the final analysis, one graduate nurse made the following
observation: “You can't be on orientation forever. And you can't be a student forever. I
think you have to learn to ask questions and learn to grow” (Hatzenbuhler & Klein 2019,
p. 95).
Undergraduate Education
There were three sub-categories of the theme of undergraduate education, i.e.,
unprepared, self-care, and managing situations. Being unprepared means that graduate
nurses do not have the psychological capital to navigate the complexity of transition.
Communication has been identified as one pivotal trait that provides the self-support
tools for success, and this has application in any context (Lee et al. 2019). Skills
inclusive of adaptability and emotional intelligence are easily transferable to manage a
myriad of situations. Clinical skills, which are often soon redundant, are not as
compelling as there will always be new developments and innovative ways of doing
things. Being able to communicate enables the graduate nurse to rise above the
practical realities to transcend them. The adjustment elements of transition shock need
to be addressed and objectified through the conduit of effective communication to
minimise the impact (Lee et al. 2019).
Unprepared
Poor practical skills were identified as an ongoing concern (Lee et al. 2019; Labrague
et al. 2019; Urban et al. 2020); however, knowledge of horizontal violence and how to
mitigate the impact was an educational need (Rosie et al. 2020; Oneal et al. 2019).
Teaching of communication skills that enable relatedness and building of relationships
was also deemed important (Zamanzadeh et al.
2015; Lee et al. 2019; Oneal et al. 2019; Kaihlanen et al. 2020). Being unprepared due
to the gap between theory and practice is characteristic of the transition experience of
most graduate nurses. It was therefore an unrealistic expectation of the graduate nurse
to already have the requisite practical skills and knowledge (Labrague et al. 2019; Lee
et al. 2019; Zamanzadeh et al. 2015). It is not uncommon for many graduate nurses to
struggle with a full complement of patients very early in their first placement, inclusive of
complex patients, for which they were not ready (Labrague et al. 2019). In many cases,
graduate nurses do not have the support expected from managers, colleagues, or
preceptors (Labrague et al. 2019). Graduate nurses need to be prepared for this reality
shock by educators (Lee et al. 2019). At the forefront is effective communication which
is considered an important area for further development in undergraduate education
(Lee et al. 2019; Oneal et al. 2019; Zamanzadeh et al. 2015).
…the key point is to build great relationships with the doctors or related
departments. This closely relates to how long nurses will survive and
stay in a clinical setting (Lee et al. 2019, p. 169).
There were many difficult conversations and communication situations identified in
which undergraduate education may benefit the graduate nurse. In this example of a
partially successful educational intervention in Sweden, Frögéli et al. (2020) undertook
a parallel randomised controlled trial with a focus on improving adaptation to stress and
social acceptance. Graduate nurses (n=239) were exposed to an education program of
three sessions of three hours each (nine hours in total), in groups of approximately ten
participants. The intervention included the following topics, i.e., the graduate nurse
transition experience, the nature of stress, stress-related ill-health, and the socialisation
process. Data were collected using self-report questionnaires using a digital survey
tool. The results indicated that there was little difference between the two groups with
regard to their stressors and fears. It was however found that adherence to the
intervention was positively associated with adaptation to stress and social acceptance
by graduate nurses (Frögéli et al. 2020). Confounding factors cited were the use of self-
reports and possible leakage between the intervention and the control group.
The following are primarily communication-focused topics identified from the literature
and advocated for inclusion in undergraduate nursing curricula for the purpose of
facilitating transition to practice:
The first of these is the requirement of full expression of the registered nurse role which
is thought to improve confidence and competence with communication skills, and
relatedness to their colleagues, seniors, and members of the inter-professional team
(Kaihlanen et al. 2020). The “manner of integration” as previously mentioned was
enhanced by what was termed “systematicness” by Kaihlanen et al. (2020), i.e., the
student had specific learning needs; there was a plan with time sufficient to demonstrate
that those needs had been met; the student’s performance demonstrated that those
needs had been met (Kaihlanen et al. 2020). Associated with performance is the
teaching of time management and prioritisation. Poor prioritisation has been
consistently reported, allegedly due to lack of knowledge, on the part of the graduate
nurse. For example, basic knowledge of the normative values of vital signs and the
patient safety implications of any differential was advocated (Hatzenbuhler & Klein
2019; Lee et al. 2019; Oneal et al. 2019; Shaw et al. 2018). Enhancement of critical
thinking to foster problem-solving in unexpected situations is also a valuable contributor
to time management and prioritisation, i.e., abrupt or sudden complaints from patients
or other challenging scenarios (Lee et al. 2019). To further complement the
development of efficacy and organisational skills, more attention needs to be paid to the
final practicum immediately prior to completion of the undergraduate program. Essential
and defining characteristics of an effective final practicum was the manner in which the
final year nursing student was integrated into the functional ward unit as an accepted
and valued part of the team (Kaihlanen et al. 2020). It was especially important for the
graduate nurse to experience full expression of the nursing role, as this was not the
usual experience. Hatzenbuhler and Klein (2019) interviewed ten graduate nurses and
all of them identified differences in nursing students' responsibilities and that of the
registered nurse when providing patient care.
Improvement of communication skills was also advocated. In particular, patient
“handover” or “handoff”, i.e., guided practice for providing a comprehensive report to the
next shift or relevant caregiver, was found to be extremely effective with regard to
transfer of accurate information (Lee et al. 2019). Telecommunication skills were also
reported as being “very difficult” for graduate nurses, and some were initially fearful and
avoided the telephone altogether (Lee et al. 2019). Contributing to these fears were the
practical difficulties of hearing a telephone conversation, and the frequent use of
abbreviations and parochial terminology used in the medical arena which was difficult
for outsiders to understand (Lee et al. 2019). As such, further education is
recommended to prepare graduate nurses so they are comfortable using the telephone
(Lee et al. 2019). Communication is also an essential facilitator of relatedness, and
relationship building was considered critical as was the development of rapport with not
only the myriad of health professionals, but also with maintenance staff, food services,
patient transport services, and pharmacy services, all considered integral to providing
comprehensive patient care (Lee et al. 2019). Finally, communicating with distressed
relatives and the management of the process of patient death inclusive of the dying
process, was elicited as a critical competency. Without clear guidance, feelings of
inadequacy can cause distress and adverse psychological trauma to the graduate
nurses, reducing their self-efficacy (Cadavero et al. 2020; Lee et al. 2019).
Self-support
Self-care and work-life balance is reported as being given a low priority in some
undergraduate nursing programs, and a higher profile is advocated when considering
strategies to ameliorate transition shock (Oneal et al. 2019; Docherty-Skippen et al.
2019). Personal self-support incorporates all of the self-care elements that contribute to
the wellbeing of the nurse as an individual, i.e., spiritual self-care, relationship self-care,
emotional self-care, psychological self-care, the capacity to navigate self-care
resources, physical self-care, self-evaluation of personal health and wellbeing, and
resilience (Docherty-Skippen et al. 2019, p. 111). The Nursing and Midwifery Board of
Australia emphasises the need for nurses to “maintain the capability” for practice, but
does not specifically include self-support competence in the ‘Registered nurse
standards for practice’ (NMBA 2016). Further research is required to determine the
undergraduate experience across the spectrum of universities in this regard. While it is
asserted by Docherty-Skippen et al. (2019) that most research in the past has focused
on the negative outcomes of attempting to fulfil the professional nursing role, little has
been written about teaching of self-support competencies to nursing students. As a
consequence, positive approaches to teaching nursing students about how to “self-
care” were advocated for by Docherty-Skippen et al. (2019). Research targeting self-
care activities and an educational approach to teaching self-care was undertaken in
Ontario, Canada (Docherty-Skippen et al. 2019). Their findings indicated that personal
self-care was overwhelmingly valued by the educators who responded to the survey;
however, it was enacted within all curricula to a greater or lesser extent. Predominantly,
it was not perceived as valuable when compared to professional self-care. There were
numerous reasons cited by Docherty-Skippen et al. (2019): individual curricula were
primarily consumed with task-related patient-centred care models and neglected the
impact that an individual nurse’s capacity to self-support might have on the process; the
capacity to evaluate achievement of self-support strategies was found to be a
challenge; and as previously mentioned, some considered self-support to be a more
individualistic need and believed it should be relegated to counselling on an individual
needs basis, i.e., when nursing students presented with problems or issues around
coping. Others believed there was already too much content in their curriculum and
were concerned about including extra information (Docherty-Skippen et al. 2019).
Managing situations
Violent patients, patient complaints, and abusive physicians are difficult situations to
deal with, and need to be addressed educationally before graduation (Oneal et al.
2019; Lee et al. 2019).
Violent patients and abusive physicians
Bullying behaviour is quite pervasive and may play a central role in the transition to
practice for graduate nurses (Rosi et al. 2020). The prevention of horizontal violence is
important as it has a negative impact on graduate nurses, both professionally and
personally (Rosi et al. 2020). Patients are also put at risk if there is reluctance to speak
up. It is not uncommon for graduate nurses to endure bullying, as they are not cognisant
of this phenomenon, what it is, how it occurs, and what can be done to address it (Rosi
et al. 2020). Interventions in the form of education are important to provide the
necessary skills to identify and contextualise bullying behaviour. Thompson (2016)
undertook a pre/post survey of graduate nurses following the completion of four bullying
modules (the intervention). Her evidence demonstrated that integration of content about
bullying into the curriculum of undergraduate nursing programs increases self-efficacy,
and has a protective effect on graduate nurses (Thompson 2016). Modules included the
importance of recognising both overt and covert bullying behaviours; developing
assertiveness as a core communication skill; avoidance of being a target of bullying;
and actions available to address bullying (Thompson 2016).
Patient complaints
The professional management of patient complaints was seen as important by both
undergraduate nurses and nurse educators (Lee et al. 2019; Law & Chan 2019). Not
having the skills to address patient complaints effectively was stressful for graduate
nurses, and can result in escalation and violence. Simulated practice was suggested as
a solution (Lee et al. 2019). The opportunity to practice the management of distressed
patients should be provided, including how to de-escalate a crisis situation and restore
harmony (Lee et al. 2019).
Structural Empowerment
There were two sub-categories of structural empowerment important to graduate
nurses, i.e., the need to feel supported; and the need to feel safe.
Need to feel supported
Structural empowerment was deemed to be an important theme overall (Mansour &
Mattukoyya 2018). Empowerment of graduate nurses is attainable through access to
opportunity, information, support, resources, and to formal and informal power
(Mansour & Mattukoyya 2018; Frögli et al. 2019). Tong et al. (2018) found that
graduate nurses (n=22) from a baccalaureate program based in the Pacific North
West of the USA were not subject to burnout or feeling out of control generally. The
more recently graduated nurses from 2015 felt that the patient load and ward culture
were fair and equitable, whereas the graduate nurses from 2003 (n=21) felt less
supported. The 2015 group felt that the workload was distributed equitably and fairly
among the nursing staff, and that the organisation valued them as new nurses. There
were however possible explanations for this change in perspective. The informants in
the 2003 study were self-selected, whereas the 2015 group were purposely selected.
On commencement as a graduate nurse, access to opportunities for growth within the
organisation is facilitated by providing the graduate nurses with choices about the
nature of their orientation to the ward or unit (Wing et al. 2019; Kim & Yeo 2019),
choices that aligned with the graduate nurse’s perceived needs and which
engendered feelings of agency, e.g., a longer or shorter orientation; a developmental
choice targeted at the development of specific skills, such as participation as an active
member of the inter-professional team, or if specific to their chosen placement,
arrangement of an introductory session on “Point of Care” Troponin measurement
with the cardiac nurse (Wing et al. 2019). Interventions which aid socialisation,
support from team members, and individualisation of their experience enhance the
perception of a supportive environment (ten Hoeve et al. 2018; Oneal et al. 2019).
When graduate nurses feel validated by their leadership, they are gifted with formal and
informal power as individuals. Validation promotes acceptance by members of the team
and their preparedness to assist. Leadership interventions which aid socialisation,
provide support from team members, and individualise the graduate nurse experience,
lifts graduate nurses’ confidence, and their feelings about the transition experience (ten
Hoeve et al. 2018; Oneal et al. 2019). Such a work environment also provides graduate
nurses with the confidence that will embolden them, not only to speak up, but also to
interact effectively with patients, colleagues, and the inter-professional team (ten Hoeve
et al. 2018; Mansour & Mattukoyya 2018). Graduate nurses will also connect with their
values and engage in advocacy with moral courage (Mansour & Mattukoyya 2018).
Wing et al. (2015) found that empowering workplaces fostered a culture with fewer acts
of incivility at all levels of the hierarchical structure. Staff were more likely to work
harmoniously, be more accepting of others, and less competitive. “Civil work
relationships are dependent on an organisational culture that resists negative,
disruptive behaviours and promotes collegial relationships” (Wing et al. 2015, p. 640).
In an empowered workplace, graduate nurses express their role more effectively, as
they have a choice of who to approach for support or advice, instead of who they
should avoid (ten Hoeve et al. 2018). There is no need to become invisible. The
graduate nurse can be creative and engage in critical thinking and not “second guess”
themselves, as would happen if they were subject to incivility. As a result, there is less
likelihood that they will make mistakes (Rosi et al. 2020). Structural empowerment
benefits the resilience of graduate nurses, whereas an uncivil workplace culture
adversely affects their mental health (Wing et al. 2015).
Need to feel safe
There were a number of recommendations for graduate nurses to feel safe. When
graduates felt vulnerable and unsafe (Law & Chan 2015), advocating or “speaking up”
for themselves or their patients was adversely affected. Feeling safe at work required
the provision of appropriate allocations of staff to reduce graduate nurses’ insecurities,
and to promote an environment free of risk (Lea & Cruickshank 2015; Laschinger et al.
2016; Oneal et al. 2019). This included the need to address horizontal violence and
encourage positive relationships (Gardiner & Sheen 2017; Wing et al. 2015).
Constructive feedback about progress can assist with feeling safe and reducing
uncertainty about performance (Gardiner & Sheen 2017). Casler et al. (2017)
advocated the use of an online intervention alleged to mitigate against feelings of
vulnerability. This study by Casler et al. (2017) and the above considerations will now
be discussed in more detail.
In Austin, Texas, U.S.A., Casler et al. (2020) undertook a quantitative study in which a
convenience sample of graduate nurse informants (n=25) were recruited from the
residency program of a large medical centre in a pre-test post-test survey. The purpose
of the study was to evaluate an online support intervention designed to improve
graduate nurse job satisfaction and competency. The intervention was active
participation in a closed, private Facebook group which provided the opportunity for
graduate nurses to express their fears about transition. “Content was semi-structured
(discussion posts, photos, polls, articles, video) with weekly topics as well as an open
forum for graduate nurses to seek advice or support”. Topics for the weekly discussion
posts were based on Boychuk Duchscher’s transition shock model (Duchscher 2012).
Graduate nurses were able to share reflective observations, challenges, and emotions
with other graduate nurses and designated mentors. The Casey-Fink Graduate Nurse
Experience Survey (Casey et al. 2004) was completed before commencing their
transition program. Graduate nurses then participated in the Facebook group for a 4
month period, after which they were re-tested, and measurement of any changes in
psychological and professional capital was undertaken (Casler et al. 2020). The post-
test survey demonstrated that graduate nurses now felt safer, i.e., when interacting with
physicians, with their discomfort levels reducing from 20.8% to 4.5%. In another
example, graduate nurse confidence in managing deteriorating patients improved from
21% pre-test to 42% post-intervention. While these examples are compelling, there may
have been confounding factors associated with the duration of the intervention. There is
a likely improvement in confidence without any intervention over a four month period, as
previous studies (Lea & Cruickshank 2015) demonstrate that graduate nurse
communication and competence improves over time. A randomised controlled trial
would verify the alleged benefit of the intervention, with one group being exposed and
the other completing the standard residency.
In their meticulous Hong Kong study, Law and Chan (2015) undertook a narrative
inquiry to examine the process of learning to speak up among graduate nurses.
Graduate nurses (n=18) were subject to a process of inquiry inclusive of multiple
unstructured interviews (12 months, 18 months, and 24 months post-graduation) and
voluntary ongoing email conversations. The results were schematically represented as
three distinct threads asserting that learning to speak up was a process that requires
intense tuition: 1) The study questioned the effectiveness of superficial safety tools such
as ISBAR, particularly when the low status of graduate nurses spoke louder than their
assertions. Consequently, more comprehensive education was advocated for all health
care professionals to facilitate cultural change so that graduate nurses will be heard. 2)
Mentoring from others and self-mentoring was deemed essential to aid the “learning to
speak up” process. It requires courage to speak up in an environment that values
conformity, face-saving, and amicable work relationships. 3) Positive cultural change
was advocated to create a safe space for graduate nurses to speak up on behalf of their
patients (Law & Chan 2015). Reluctance to speak up in a different context was
discovered by Lea and Cruickshank (2015), who conducted in-depth interviews with
experienced registered nurses (n=16) in rural New South Wales. The registered nurses
expressed concern that when graduate nurses were feeling apprehensive and anxious
about fulfilling their role, they failed to speak up, i.e., “participants felt that new
graduates in general actually needed support to seek support” (Lea & Cruickshank
2015, p. 2831). Seeking support was also deemed important in the “photo voice” study
of resilience by Wahab et al. (2017). Taking control of emotions, self-motivation, and
taking the initiative to seek help was reported as a strategy used by resilient graduate
nurses in order to feel safe and not overwhelmed (Wahab et al. 2017; Cadavero et al.
2020). Intra-personal resilience in the form of psychological capital and personal job-fit
were also positively correlated with career satisfaction in the large national Canadian
survey by Laschinger et al. (2016).
Another significant contribution to the graduate nurse feeling safe and free of anxiety
was the provision of copious amounts of formal feedback on performance.
Unfortunately, Gardiner and Sheen (2017) discovered that it was not unusual for
graduate nurses to receive minimal or inappropriate feedback throughout their graduate
year. For some, this reflected a ward culture of bullying, “The feedback I received
reflected the lack of support and bitchy nature of the ward” (Gardiner & Sheen 2017, p.
12), while others received little feedback at all. In their online survey of graduate nurses
(n=107), Gardiner and Sheen (2017) found, when using a bivariate regression, a
negative relationship between feedback and anxiety. A one-way analysis of variance
showed that the degree of distress experienced by graduate nurses was directly related
to the frequency and quality of feedback provided, i.e., graduate nurses provided with
frequent and quality feedback were less anxious. Avoidance of graduate distress was
deemed to require quality feedback which is planned, respectful, and appropriate with
regard to time and place. For such feedback to be effective, it also needs to be labelled
as feedback, and be objective, fair, based on evidence, and clearly provided by an
assessor who has actually observed the graduate nurse in a supervisory capacity
(Gardiner & Sheen 2017).
Work place incivility was another challenge to feeling safe. Laschinger et al. (2016)
found that graduate nurses in Canada felt safer than those in most other jurisdictions
with regard to workplace incivility. However, uncivil behaviours from medical staff,
senior nurses, and fellow workers remained a factor that significantly influenced
outcomes for graduate nurses, i.e., burnout and emotional exhaustion. To mitigate
against this phenomenon, the authors speculated that planned reduction in both
incivility and disrespectful behaviours between staff at all levels would translate into a
less hostile and more harmonious workplace culture (Laschinger et al. 2016). This need
for mitigation against uncivil behaviours was reinforced by Wing et al. (2015) in another
Canadian study which focused specifically on the state of Ontario, entitled ‘Violence
prevention needs to target the attitude of experienced nurses towards young nurses,
who should be respected and valued as important members of the health care team’
(Wing et al. 2015, p. 641).
The demands of nursing work environments are omnipresent for graduate nurses
worldwide and in different forms. In the Philippines, Labrague et al. (2019) reported on
the challenges of rural graduate nurses and the lack of support mechanisms and
pressure of caring for a high caseload of patients. Staff were reluctant to provide
assistance and expected them to hit the ground running. Lea and Cruickshank (2015)
also discovered from interviews with experienced registered nurses (n=16) in New
South Wales (n=14 health units), that skill mix and the demands of the rural
environment precluded the graduate nurse from gaining effective support. The reasons
cited were a lack of resources, lack of willingness to provide support, and lack of
knowledge of the needs of graduates. Furthermore, the registered nurses from New
South Wales informed the interviewers that the graduate nurse was at times left
particularly vulnerable as the only registered nurse rostered “on” for the entire hospital,
and therefore, “in charge” of an early shift or night shift accompanied only by
enrolled/practical nurses. Laschinger et al. (2016) also asserted that a major
contribution to incivility to graduate nurses in Canada was the tension and work life-
imbalance arising from short-staffing and higher levels of patient acuity. Apart from the
inherent psychological risks to safety, there were also many associated physical risks.
In this first example, Oneal et al. (2019) discovered that every participant in their focus
group study of graduate nurses (n=34) was challenged by their lack of experience with
managing aggressive patients, and angry relatives and their friends. They were
challenged by the associated threats which included lack of security and feeling
vulnerable, such as when going to the car park at night, or by falling asleep while
driving home after a night shift. Ever-present were the ergonomic risks from lifting
patients, needle stick injuries, or manual handling of aggressive patients.
Preceptorship
There were three categories of significance for preceptorship synthesised from the
research: firstly, the recommendation of adequate education for preceptors; recognition
that preceptorship can be a negative experience; and acknowledgement that
preceptorship, where implemented effectively, can be an extremely effective support for
the graduate nurse. The overarching revelation is that a health service with a preceptor
program provides no guarantee of support for graduate nurses unless it is adequately
resourced and fully supported by the nursing department.
Education needs
Education needs for preceptors were advocated for in a number of sources. In studies
by Charrette et al. (2019) and Ziebert et al. (2016), there were similar findings of under-
resourcing and a need for improved managerial support. Firstly, Charrette et al. (2019)
completed focus groups in the French-Canadian city of Montreal with (n=19) informants.
This 360° study was comprised of graduate nurses (n=4), nurse preceptors (n=2),
clinical nurse specialists (n=9), and nurse managers (n=4). Overall, the group reported
the need for a longer orientation that would cater to the needs of individual preceptors.
In addition, some felt inadequately prepared and that further preparation would make
them more effective. There were similar experiences in Milwaukee, Wisconsin, USA as
reported by Ziebert et al. (2016), in which graduate nurses (n=118) were debriefed on
three occasions in a 12 month longitudinal study. Informants were divided into groups
(n=8-10) for debriefings on each occasion. The findings advocated for improved
preparation for the role of preceptors and an emphasis on the allocation of additional
time for preceptors to fulfil their educational role. Feedback on preceptor performance
was lacking, and graduate nurse informants indicated that the opportunity to appraise
preceptor performance would be helpful (Charette et al. 2019; Ziebert et al. 2016). A
major concern for the studies of Charette et al. (2019), Wahab et al. (2017), and Ziebert
et al. (2016) was the frequency with which individual graduate nurses were allocated
multiple or absent preceptors on a shift-by-shift basis. Ziebert et al. (2016) asserted that
without a dedicated preceptor, graduate nurses felt a lack of certainty with their
educational development, causing severe compromise to the important relationship
between support and learning.
Negative effects
In Tainan, Taiwan, Ke and Stocker (2019) conducted in-depth interviews with graduate
nurses (n=20). The interview data were richly described, reporting the preceptors’
experiences of graduate nurses in-depth. It was clear in their study that preceptors can
have a negative influence on graduate nurse self-esteem, particularly where graduate
nurses have to prove themselves to gain acceptance or face being shunned (Ke &
Stocker 2019). A not uncommon example illustrating the negative influence of a poor
preceptorship relationship is the rich description provided by one graduate nurse, “I was
mentored by a real jerk of a preceptor. She would ask me lots of questions and roll her
eyes when I was unable to answer her” (Ke & Stocker 2019, p. 4325). Other preceptors
would make the graduate nurse feel worthless and create “deep seated memories of
bitter suffering” (Ke & Stocker 2019, p. 4325). Shaw et al. (2018) argued that such
tension occurs
in the preceptorship relationship when preceptors are forced into the role, causing
graduate nurses to intuitively feel the disharmony, whether there is overt hostility or not.
Consequently, patient safety can be compromised; if the preceptor is particularly harsh
in the event that a graduate nurse reports an error, it increases the likelihood that on
future occasions, the graduate nurses will keep quiet to avoid reprimand (Ke & Stocker
2019). Paradoxically, it was reported that graduate nurses who advocate evidence-
based practice or have better skills, can make the preceptor feel threatened, adversely
affecting their relationship with the preceptor and their social acceptance on the unit
(Charette et al. 2019). Striking the right social balance to not stand out is a difficult
challenge for the graduate nurse. If there is an error of judgement by the graduate
nurse, intimidation by preceptors is an unfortunate reality (Charette et al. 2019).
Positive Effects
Good preceptor relationships are a possible outcome for graduate nurses; however,
preceptors require education, willingness, and available time to fulfil their role. They
also need a leadership team that will schedule their shifts appropriately and support
them. Some preceptors believe that it is often the personality of the graduate nurse that
determines the outcomes with regard to the preceptor relationship (Shaw et al. 2018).
However, where preceptors were invested in supporting graduate nurses, the
relationship worked well (Ke & Stocker 2019; Charette et al. 2019).
Having a consistent and proper supervision is important. I am always
attached to my preceptor…my main preceptor always seems to know my
progress. Also my preceptor did debriefing and I think it was very good
(Wahab et al. 2017, p. 47).
As a consequence, this investment usually resulted in overall positive outcomes for
the graduate nurse, including improved social acceptance and relatedness on the unit
(Ziebert et al. 2016; Wahab et al. 2017). Furthermore, in a large Canadian study of
400 informants, Laschinger et al. (2016) reinforced previous findings that most
graduate nurses (90%) found preceptorship to be a significant factor contributing to
their success.
Discussion and recommendations
Much of the international literature around the psychosocial factors associated with
transition has focused on postgraduate experiences of transition to professional
practice, rather than on purposive psychosocial preparation of nursing students for
transition to practice. Are graduate nurses to be bystanders dependent on health units
for provision of a supportive framework for success, or are they to be enthusiastic
engaged actors who self-initiate and self-mentor? How do nursing students
successfully transition to graduate nurse?
