Strategies new graduate registered nurses require to care
and advocate for themselves: A literature review
This publication which emerged from study 3, further illuminates the nature of inconsistent support
of graduate nurses, in particular, the many incidents/issues requiring self-belief, initiative, and
resilience. Considered more than a hand-maiden, the graduate nurse has many self-support
strategies they can adopt to succeed. My contribution to publication 3 as corresponding author is
detailed below. (An authorship declaration is included in Appendix 5).
Citation
Mellor, P.D., Gregoric, C. & Gillham, D.M. (2017). Strategies new graduate registered nurses
require to care and advocate for themselves: A literature review. Contemporary Nurse, 53(3), pp.
390-405. [10.1080/10376178.2017.1348903]
Journal Impact factor: 1.3 Citations: 21 (See Appendix 4 for details)
Authorship statement and publication background
I was project champion for this study which began at the Flinders University Rural Clinical School
(Riverland SA) with a detailed initial search undertaken by myself. This integrative review was
undertaken initially to underpin an application for a university establishment grant to study the
extent to which graduate nurses self-initiate their own support. I later sought to have the results of
the critical review published, and consulted with two co-authors at different stages of an extended
process (due to various circumstances) of approximately 3-4 years. In the first stage, Associate
Professor David Gillham contributed to the manuscript primarily acting as a consultant and
agreeing to be designated second co-author. By completion of the second stage, the manuscript
had undergone significant changes. Dr Carolyn Gregoric reviewed the publication drafts and, as a
result of her more detailed involvement, it was agreed that she be designated as first co-author.
Research design: The PRISMA reporting of search strategy was used to record the publications
identified for this integrative review. The designation of key words and the search was undertaken
primarily by myself with a focus on the narrative related to strategies that graduate nurses use to
advocate and care for themselves. Further detail on the process has been provided in Chapter 1.
Data collection and analysis: I designed the literature review inclusion/exclusion criteria. Key words
were often insufficient to identify relevant articles, and reading of the text of each article to identify
the strategies used by graduate nurses was required. I used a pen to highlight the
issues/strategies identified in each article, placing them initially into two major categories, i.e.,
‘graduate nurse issues’ and ‘graduate nurse resilience factors’. There was a large number of
articles requiring scrutiny and it took a number of days to complete the analysis. Frequently, the
title of the article did not provide any indication that a potential resilience strategy may be
contained within. The results were detailed on a spreadsheet in two groups. The first grouping
contained a list of strategies that graduate nurses have used successfully during transition. The
second grouping highlighted issues relevant to graduate nurses. Overall, there were issues and
resilience factors identified in 80 relevant articles. This data was synthesised by myself to create a
detailed theoretical framework and conceptual model of the results (see Figure 2). Dr. Carolyn
Gregoric provided feedback with regard to the figure designs and inclusions.
Writing and editing: I wrote the initial draft, designed the figures, and wrote the subsequent drafts.
As corresponding author of the article, I was responsible for attending to the adjustments as
requested by the publisher of Contemporary Nurse. As the manuscript neared completion, editing
and adjustment was primarily undertaken in consultation with Dr. Carolyn Gregoric. The
manuscript was also provided to Associate Professor David Gillham for contributions and
suggestions with regard to editing at each stage of review and revision. A complete version of this
publication is included on the following pages.
Strategies new graduate registered nurses require to care and advocate
for themselves: A literature review
Abstract
Background
New graduate registered nurses are confronted with a complex, demanding and resource
constrained environment where gaining acceptance into the workplace culture may be difficult.
Existing evidence suggests that preparing undergraduate nursing students for this reality can
assist with adjustment.
Objectives
To identify the strategies that new graduate registered nurses require to care and advocate for
themselves during their first year of practice.
Methods
A search of the literature published between 2001 and 2016 was undertaken. Individual articles
were synthesized narratively and the results entered to a summary table.
Results
A total of 274 articles were considered relevant to this narrative review. This paper synthesized the
narrative of 80 articles. Synthesis revealed 22 resilience factors and 33 issues. Eight strategies
with potential to assist new graduate registered nurses to care and advocate for themselves were
identified. All of them socioemotional in nature.
Conclusions
This review of the literature provides a valuable resource that can be used to prepare nursing
students for the workplace culture during their first year as a registered nurse. Scenarios can be
developed for educational activities such as simulation, role play, discussion and self-reflection.
Further development through research is recommended.
Keywords: new graduate nurse; self-care; self-advocacy; transition to practice; novice; coping
strategies; self-efficacy; resilience; hardiness.
Introduction
In Australia and many other western countries internationally, new graduate registered nurses
(NGRNs) are not considered to be work ready by employers and transition to professional practice
programs (TPPPs) are provided as a panacea. In contrast, Zamanzadeh (2014) noted that some non-
western countries focus on the resilience of the NGRN and any formal transition support may
extend to as little as 14 days. This observation creates the following causality dilemma: Has the
rise of TPPPs influenced the preparation of undergraduate nursing students by lowering
performance expectations of graduates or is it the lack of preparation that has influenced the rise
of TPPPs? Unfortunately the western paradigm relies on the latter i.e. transition programs of
health organizations address gaps in practice not serviced by the university sector. This paradigm
has the effect of making universities impassive in their preparation of students for nursing practice.
For example, one of the first challenges that NGRNs have to encounter is shift work. How do
universities explicitly prepare them for this phenomenon? How do they prepare students for inter-
professional practice and the practice conflicts, politics and inevitable horizontal violence that
occurs? These questions are not often answered in curricula and nursing students are unaware
that the reality of the health care environment is one of limited support, extreme challenge and
unpredictability (Boychuk Duchscher, 2012).
Limited support for NGRNs remains likely into the foreseeable future as overstretched health care
institutions struggle financially. Even though there were pre-existing (i.e. prior to 2007) concerns
(Delaney 2003), the global financial crisis has contributed even further to the decline of transition
support. This has been reported throughout the OECD and world-wide (Morgan & Astolfi, 2014).
As a result, the likelihood that promises, such as preceptorships, not being realized are more
likely (Healy & Howe, 2012). The following quote provided by Wangensteen, Johansson and
Nordstrom (2008) illustrates the European Union experience.
We were supposed to have a supervisor – we were supposed to have guidance in groups
– it all looked so fine. But we haven’t had any of that (….) It was very disappointing.
(Wangensteen et al., 2008, p.1880)
Many resilience strategies are advocated in the current literature (Benner, 1984; Duchscher,
2009; McAllister & Lowe, 2011; Schoessler & Waldo, 2006), however further research is required
to identify the explicit resilience strategies NGRNs might adopt to thrive throughout their graduate
year. McAllister and Lowe (2011, p.6) define resilience as ‘a process of adapting to adversity that
can be developed and learned’.
Being prepared for the reality of diminished support is critical to the NGRNs success and
preparation is essential in the form of practical strategies that enhance their foreknowledge and skill
to manage potential dilemmas. The aim of this review was to identify the strategies from previous
research that are most likely to assist NGRNs to advocate and care for themselves.
Background
Despite many reports and recommendations to the contrary, the likelihood that NGRNs will find
themselves in a chaotic, dysfunctional or unsupportive work environment remains quite high
(Adlam, Dotchin & Hayward, 2009; Dyess & Sherman, 2009; Kelly & Ahern, 2009; Romyn et
al., 2009; Clark & Springer, 2012; Chandler, 2012; Berry et al., 2012; Feng & Tsai, 2012; Hart,
Brennan & de Chesnay, 2012; Laschinger & Grau, 2012; Thomas, Bertram, & Allen, 2012).
The NGRN often experiences both physical and emotional exhaustion and is also likely to
experience anxiety, low self-esteem, despair and a sense of hopelessness when trying to ‘fit
in’ to the new health unit environment. Due to this stress, many leave nursing as a career
(Greenwood, 2000; Cubit, 2011; Halfer & Graf, 2006; Figueroa et al., 2013; Wu 2012). The
most often reported reasons for NGRNs leaving their first position as a registered nurse relate
to:
• Stress associated with acuity of clients, unacceptable patient/nurse ratios, feeling patient
care was unsafe (Bowles & Candela, 2005)
• role stress and oppression (Duchscher, 2008; Duchscher & Myrick, 2008; Douglas, 2014;
Kovner et al., 2007)
• lack of management support and too much responsibility (Morrow, 2009)
• shift work, overtime and night shift interference with family life (Morrow, 2009)
• senior staff not perceiving that support is needed (Parker, Plank, & Hegney, 2003)
• promises such as preceptorship not eventuating, preceptorship being inadequate or the
preceptor unwilling or unprepared to be supportive (Clark & Springer, 2012; Delaney, 2003;
Harrison- White & Simons, 2013; Parker et al., 2014).
The contribution of the health care environment to the transition of NGRNs has received a great
deal of attention as illustrated above. However, discussion with regard to the contribution of the
academic environment and best practice with regard to addressing reality shock and self-care
needs have been minimal. It is anticipated that by identifying the self-care strategies adopted by
successful NGRNs and exploring the issues which impact on the capacity to successfully navigate
their transition year, curricula can be developed to provide the appropriate education and
resources.
Method
A literature search was undertaken and key terms were used in an attempt to identify reported self-
care strategies or issues relevant to the NGRN. However, use of key terms alone was
unsuccessful and searching within the articles by reading of the text and identifying the strategies
and issues discussed was required. For example, in the study by Mooney (2007a) the text
supported the need for strategies to address reconciliation of mistakes, however the title of the
article ‘Professional socialization: the key to survival as a newly qualified nurse’ did not reflect this
content. As such, forensic searching of the text within the articles was necessary to identify the
potential resilience strategies important NGRNs.
The inclusion/exclusion criteria was designed to maximise the possibility of locating the self-care
strategies required by NGRNs during professional socialization.
Inclusion criteria
Inclusion criteria focused on critical research that informs the challenges, self-care strategies and
issues of relevance to the NGRN during their transition year. International and local articles that
were written in English and reveal the experience of NGRNs in the acute care environment were
included. This broad criteria was adopted so that the key elements and self-care strategies which
contribute to empowerment of the NGRN could be identified.
Exclusion criteria
Acuity of clients and feeling that patient care is unsafe has been reported as a significant role
stress (Bowles, 2005; Duchscher, 2008). As such articles were excluded if the targeted population
of NGRNs undergoing transition was not in an acute care environment. Also excluded were
instances where experience and further training was an organizational requirement required before
the NGRN was eligible to commence the training program being researched.
Search strategy
An online literature search was completed between 2001 and 2016, in CINAHL, Ovid Medline,
Informit, Google Scholar, and Web of Knowledge using the search terms: new graduate nurse,
self-care, self-advocate, transition to practice, novice, coping strategies, self-advocacy, self-
efficacy, self-esteem, resilience, hardiness, and self-management.
Many combinations of search terms were used to ascertain possible relevance to NGRNs. Articles
were read and assessed with regard to strategies or issues relevant to NGRNs. After forensic
examination, many were found to contain strategies that had been adopted or issues that needed
to be addressed by the NGRN to care and advocate for themselves. Findings were recorded on a
Microsoft Excel spreadsheet for analysis and categorization.
As illustrated in figure 1 a total of 445 articles resulted from the initial search that met the inclusion
criteria of possible relevance to NGRNs. Once duplicates were removed 274 articles were
screened in accordance with the inclusion criteria. Of these, 139 full text manuscripts were
selected for further screening. Of these 80 articles were found to contain self-care strategies that
had been adopted or issues that needed to be addressed by the NGRN. Findings were recorded
on a spreadsheet for analysis and categorization. This process continued until no further new
strategies or issues were found.
Each article was read in order to answer the question, ‘What self-care strategies or issues within
this manuscript are relevant to the NGRN?’ When self-care exemplars were identified they were
allocated to a purpose designed Microsoft Excel summary table. A conceptual model of results is
provided in Figure 2.
In developing the strategies, the researcher was sensitive to the elements of reality shock that
presented. Strategies were categorized with a focus on the resilience factors and also the issues
identified as being significant for NGRNs. For example, it is acknowledged that horizontal violence
is an issue of socialization however it is considered to need special attention because of
prevalence and the negative effect it can have on performance. It is also acknowledged that the
nature of social and emotional skills and the manner in which they are allocated is dependent
significantly on the situated context and judgement of the researcher (Blyth, Olson, & Walker,
2015; Braun & Clark, 2006).Results
Research that specifically targets the preparation of nursing students for the realities of
practice with a focus on resilience was relatively small (Zamanzadeh, 2014). The title of articles
did not always reflect the content and reading of the text was required in order to identify the
self -care strategies.
Identified strategies included the need to: explore personal self-support, reflection and interpretive
style, address social intelligence and the need of the NGRN to fit into the organizational culture;
understand the nature of transition; minimize horizontal violence, recognize and regulate emotions;
manage moral distress and foster moral courage; self-assess progress and performance. Details
of these findings will now be discussed:
Strategies of Interpretive style, Reflection and Personal self-support
Sixty-five articles out of 80 related the importance of interpretive style, reflection and personal
self-support. Stress is reported to negatively impact the quality of care provided by new graduate
registered nurses (Thiesen & Sandau, 2013). Management of stress is more effective where
NGRNs have good psychological capital. Psychological capital is described by Boamah and
Laschinger (2015, p.267) as a “positive psychological state of development that comprises
confidence, optimism, hope and resilience.”
Psychological capital in the form of interpretive style is a significant factor in determining personal
self-support for the new graduate registered nurse. Interpretive style is how a nurse imagines
their own ability to perform. This occurs positively through seeing oneself as being effective with
regard to professional skills and not imagining failure (Simoni et al., 2004). ‘Interpretive style can
empower, reduce job stress and contribute to job satisfaction for that same RN’ (Simoni et al.,
2004, p.223) with the outcomes being increased self-efficacy and confidence.
Nursing students can learn to manage stress by reflecting on scenarios in which they have the
opportunity to choose from a number of interpretations, including both effective and ineffective
cognitions. These activities may enable them as NGRNs to reflect on their habitual ways of
perceiving stressful situations and provide empowerment (Simoni et al., 2004; Caldwell &
Grobbel, 2013). In addition to reflection, guided imagery has been advocated as a model for
refining the transition process with benefits such as empowerment, achieving positive outcomes
and practice proficiency (Boehm & Tse, 2013).
Spirituality can also provide meaning and help with gaining a positive perspective and source of
renewal (McAllister & Lowe, 2011). Lazar (2010) undertook a study among female Israeli nurses
and found job satisfaction was linked strongly to the sacredness of life, altruism and idealism
aspects of spirituality. Deliberately redirecting the locus of concern from the self to a focus on
‘connection’ with patients and families has the reported benefit of providing positive rewards
(Clendon & Walker, 2012, p.558). Overall satisfaction in the spiritual domain was found to spill
over positively into the work domain.
The demands of shift work often results in the NGRN feeling fatigued, overwhelmed and
dislocated from friends, family and societal norms. Students need to explore the ministration of
these concerns more explicitly prior to taking on the role of registered nurse (Ashton, 2015;
McCalla-Graham & De Gagne, 2015; Pennbrandt et al., 2013). Similarly, students need to learn
the difficult task of prioritizing and managing their patient allocation, a portion of which, may
involve death, grief or trauma (Ratta, 2016; Zeng Lee & Bloomer, 2015; Brisely & Wood, 2004;
Thiesen & Sandau, 2013).
Ultimately it is important that NGRNs recognise when help is required and take control. An
effective way to ameliorate the impact of critical incidents involving the above is to offer or request
a “debrief” if that service is provided (Shinners, 2016; Brisley & Wood, 2004; Mellor & Greenhill,
2014). In absence of a debrief, then being aware of and accessing the resources available such
as the employee assistance program is vital (Shinners, Africa & Hawkes, 2016).
Strategies of Social intelligence and fitting in
There were 49 articles of the 80 articles that included social intelligence and fitting in as a
concern for NGRNs. Walker and Campbell (2013) identify social intelligence as a critical work
readiness factor. In fact, Feng and Tsai (2012) assert that NGRNs found ‘learning how to solve
the gap between knowing and practising was easier than learning how to behave appropriately
and to deal with people in the workplace’ (p.2068).
Social intelligence is the ability to inspire, influence, empathize and care for others (Johns
Hopkins University, School of Nursing ND) or as Karl Albrecht (2004, p. 1) put quite simply
'social intelligence is the ability to get along well with others, and to get them to cooperate with
you.'
The relationships and networks which an individual has developed within an organization are
significant (Taylor, 2012). Those who have strong connections and support within an
organization are likely to have more success than those who do not (Taylor, 2012). There is
also the vital need that NGRNs have to ‘fit in’ to the clinical situation to which they are allocated
and the importance of being accepted by senior staff (Feng and Tsai, 2012; Malouf & West,
2011). Minor indiscretions such as not observing meal break times, being late for work or being
disrespectful can present as major obstacles to the acceptance of a new nurse on the ward.
There are also other significant concerns based around the perceived shame of not knowing,
which challenge the NGRNs sense of self and patient safety (Feng & Tsai, 2012; Hamilton,
2005). NGRNs reported that ‘not wanting to be regarded as stupid’ had a significant influence
on their help seeking behaviour or reporting of mistakes (Crigger & Meek, 2007; Malouf &West,
2011; Pennbrandt et al., 2013). The potential for the NGRN to jeopardize patient safety by
avoidance of shame was found to be significant, particularly at the beginning of a new
placement (Malouf & West, 2011). As a result, high risk patients are particularly stressful to the
NGRN owing to the possible consequences for the patient and fear of retribution (Ratta, 2016;
Crigger & Meek, 2007).
Findings of graduates' fear of other staff members and their reprimands along with limited
assessment capacity could potentially lead to delay in early medical intervention for the
deteriorating patient. (Purling & King, 2012 p. 3461)
Development of trust in others to assist is important for the NGRN and a recommended mindset
for NGRN’s is to feel comfortable with not knowing everything (Cooper, Taft & Thelen, 2005).
This requires access to a network of support in the form of a skilled person or mentor and
knowledge of other supportive resources (Ethridge, 2007; Hodges et al., 2008; McKenna &
Newton, 2008; Nugent, 2008). Consequently, it is important to adopt a proactive approach when
going to a new clinical area, one which comprises the asking of questions by the NGRN about
salient aspects of the routine and the staff who will be supportive (Feng & Tsa, 2012; Malouf &
West, 2011). Another strategy considered helpful for fostering engagement and enlarging the
network of support is to become actively involved in the health service through committees or
projects (Bowles & Candela, 2005).
The strategy of understanding the nature of transition
There were 17 articles of the 80 that focused on the nature of transition and the need for
NGRNs to be aware of the enormity of this change (Malouf & West, 2011). The experience of
transition shock is well documented (Duchscher, 2009; Boychuk Duchsher 2012) and NGRNs
need to understand the nature of this shock so that they can prepare emotionally, physically,
developmentally and intellectually (Duchscher, 2009; Malouf & West, 2011; Romyn et al., 2009;
Ashton 2015). This includes role conflict between long-established hierarchical nursing
traditions and what was learnt as an undergraduate (Kelly & Ahern, 2009). Learning about the
nature of transition within the syllabus as an undergraduate nursing student may empower the
NGRN. ‘Transition’ in the context of ‘transition to practice’ encompasses giving up being a
student and taking on the whole new world of being an employee and a registered nurse with all
that it entails (Benner, 1984; Boychuk Duchscher, 2012; Duchscher, 2008; Schoessler & Waldo,
2006). Each transition model has distinct developmental phases which highlight that the NGRN
is a work in progress and not a finished product. NGRNs are reported to benefit from
understanding this continuum so that they can contextualize the difficulties they may have when
comparing themselves with expert or more experienced nurses (Burger et al., 2010; Hartigan et
al., 2010).
Strategies to minimize Horizontal violence
15 articles of the 80 articles dealt explicitly with horizontal violence and the NGRN. However,
fear of retribution, avoidance behaviors, poor relationships with preceptors and complaints of
unsupportive staff featured in many other articles.
Horizontal violence and harassment in its many forms are often experienced by the NGRN
(Kovner et al., 2007; Kramer et al., 2012; Laschinger & Grau, 2012; Morrow, 2008). In fact,
Laschinger and Grau (2012) found that one third of NGRNs experienced workplace bullying,
with those under the age of 30 years experiencing bullying for a longer period than their older
counterparts (Clendon & Walker, 2012). Sexual harassment was also reported as more
common among younger NGRNs of both genders (McKenna et al., 2003). Surprisingly, Berry et
al. (2012) related that often ‘the experienced nurses expected to mentor and provide support to
NNs [Novice Nurses] are the primary perpetrators of WPB [Work place bullying]’. Other
perpetrators were staff nurses (44%) and nurses in leadership positions (19%) with physicians
accounting for only 6% of reported bullying (Berry et al., 2012). Feng and Tsai (2012) also
found physicians were much less problematic regarding bullying behaviour than were senior
nurses. This is significant as NGRNs often feared talking to physicians because of reported
stories of abuse (Hodges et al., 2008; Thomas et al., 2012). Effective communication between
clinicians, other staff and students was identified as a strategy to decrease horizontal violence
(Curtis, Bowen & Reid, 2007). ISBAR (Finnigan, 2010) - a well-recognised formalised handover
communication tool incorporating Identification, Situation, Background, Assessment and
Recommendations - was found empowering to the NGRN in the context of providing a
predictable means of communication between health professionals (Goodwin-Esola, Deeley &
Powell, 2009).
Berry et al. (2012, p.84) found significant correlation between work place bullying and negative
work productivity of novice nurses. Development of psychological capital is considered both a
personal resource and protective factor against adverse outcomes for patients (Laschinger &
Grau, 2012):
Psychological capital, a personal resource, influenced new graduates’ sense of fit between their
job expectations and their actual working conditions, which in turn influenced the extent to which
they reported experiencing bullying in the work place (p.289).
Providing nursing students with skills to address the issue of bullying in the workplace may
help them see their experiences more objectively and reduce the likelihood that bullying is
perpetuated by successive generations of NGRNs (Berry et al., 2012; Curtis et al., 2007;
Laschinger & Grau, 2012; Pines et al., 2012).
Strategies of recognizing and regulating of emotions
There were 12 articles of the 80 articles that included recognizing and regulating of emotions
as a concern for NGRNs. Essentially, emotional intelligence is about self-regulation and
mastery of emotions (Zito, 2012). In particular, Freshwater and Stickley (2004) assert that
emotional intelligence should be integrated throughout the nursing curriculum to facilitate the
essential leadership skills in learning to care for one-self and others. Emotional intelligence
competency requires self-awareness. This includes knowing one’s own strengths and
limitations, being mindful of feelings in the moment, and knowing how feelings can affect
decision-making and other people (Yale Centre for Emotional Intelligence, 2013; Rochester et
al., 2005). Emotional intelligence is defined as:
A type of social intelligence that involves the ability to monitor one’s own and others’
emotions, to discriminate among them, and to use the information to guide one’s
thinking and actions. (Mayer & Salovey, 1993, as cited in Johns Hopkins University,
School of Nursing. n.d., p.1)
To illustrate the potential value of emotional intelligence, a study was undertaken by
Rochester et al. (2005) with regard to the capabilities of 17 NGRNs rated by their supervisors
as successful. It was noted that during stressful situations the successful graduates
demonstrated more highly developed emotional intelligence and clarity of thinking (Rochester
et al., 2005).
A number of other articles also considered emotional intelligence essential for effective
leadership
and nursing performance (Beauvais, Brady, O’Shea & Griffin, 2011; Freshwater & Stickley,
2004; Kooker et al., 2007). This includes providing students with the skills to relate inter-
professionally at all levels so they have equitable influence on patient care planning and
advocacy (Bulmer-Smith, Profetto-McGrath, & Cummings, 2009; Shanta & Connelly, 2013; Pfaff
et al., 2014). These skills for dealing with emotional information need to be developed in nursing
students through education and support (Bennett & Sawatsky, 2013; Rochester et al., 2005;
Towell, Nel & Muller, 2015).
Strategies to manage moral distress and foster moral courage
There were 10 articles of the 80 articles which focused on moral distress and moral courage as
a concern for NGRNs. McAllister and Lowe (2011) highlighted the importance of learning to
manage moral distress, particularly where there is conflict between insufficient time for care
and being true to one’s own values and those learned. This can result in stress, conflict of
conscience and an impoverished sense of self:
They were extremely hard on themselves when they felt they had failed to identify or
appropriately intervene in a changing clinical situation. Despite the fact that many of
the situations in which they were placed were beyond their intellectual or physical
capability, their behaviour was consistently self-deprecating. (Duchscher, 2008,
p.445)
In addition, the self-expectations of NGRNs are often distorted by their beliefs about their
ability to handle moral distress issues in practice (Juthberg et al., 2007). Schluter et al. (2008,
p.306) describes moral distress as:
An emotion that is expressed when the moral complexity of a situation is not leading to a
resolution, thereby having the potential to cause harm to the individual nurse […] painful
feelings and associated mental anguish as a result of being conscious of a morally
appropriate action, which, despite every effort, cannot be performed owing to
organizational or other constraints.
Cooper et al. (2005) discuss how third-year students had forethought and anxiety about the
roles they would perform in their graduate year. ‘Several students discovered errors either
made by others or themselves during their clinical experience. This raised significant fears
about their responsibilities as an RN’ (Cooper et al., 2005, p.296). This level of responsibility
and accountability cannot easily be tested as an undergraduate (Hickey, 2009; Zheng, Lee &
Bloomer, 2015). However, it is possible for students to be given the opportunity to explore the
relationship between moral distress and moral courage in the context of future practice. In
actuality, moral courage in practice is considered an effective response to moral distress
(LaSala & Bjarnason, 2010).
Strategies to assess progress and performance
7 out of 80 articles provided information with regard to the reluctance of staff to assess and provide
formal feedback on NGRN’s progress and performance. Developmental and positive feedback has
been reported as helpful for providing a feeling of developing competence over the course of the
graduate year (Hamilton, 2005; Parker et al., 2014; Wangensteen et al., 2008). NGRNs
preparing for their first year in practice and in the early stages are eager to receive feedback on
their progress (Mellor & Greenhill, 2014; Wangensteen et al., 2008). Yet articles from Europe
and Australia have demonstrated that more experienced nurses are reluctant to provide
effective feedback (Wangensteen et al., 2008; Parker et al 2014). The opportunity to reflect on
practice and view challenges as learning experiences is purported to assist with resilience and
the development of a positive perspective (Wangensteen et al., 2008). In particular, Generation
Y individuals born between 1981-1994, who represent a large proportion of current NGRNs,
desire quick and continuous feedback (Keepnews, Brewer, Kovner & Shin, 2010; Lampe,
2011).
Although many of the participants (new graduate registered nurses in a graduate nurse
program) felt strongly about their own responsibility and need to pursue help if necessary
and not to be reluctant or deterred by lack of interest by their senior colleagues, they
reported they would have benefited from constructive feedback about their performance.
Often the only feedback they received was based on the fact that no-one was complaining
or no major mistakes had been made. They would have preferred some encouragement
and genuine interest in their performance. It would have helped with their confidence and
reduced the stress they experienced from not knowing how others perceived their
performance. (Parker et al. 2014, p. 154)
Due to the importance of receiving feedback on performance, it has been suggested that, in the
absence of formal feedback, nursing students should be prepared to find options and be
proactive in this regard. Assertively seeking progress meetings can be a resilience strategy for
the NGRN in order to reaffirm progress, instil a sense of achievement, explore learning
opportunities and set new goals (Goodwin-Esola et al., 2009).
If attempts to gain feedback are not successful, there are alternative or complementary
options, such as maintaining a portfolio, reflective journal or being alert for other measures of
success (Sewell, 2008). These measures may include feedback from patients, being given
extra responsibility or informal feedback on practice during the course of the shift etc. Those
who have had experience with a reflective journal find that writing assists with self-assessment
of progress, provision of perspective and a sense of achievement (Day & Rickard, 2012).
Additionally, the use of social media and web blogs as a critical event journal has been
suggested for debriefing and shared learning (Sewell, 2008).
Discussion
There is reported to be little research on how to manage specific stressors associated with reality
shock (Thiessen, 2016). The objective of this literature review was to identify research that has a
focus on the strategies NGRNs employ to manage these stressors. It is also acknowledged that
every student will have a different capacity for resilience. At the outset, nursing may have been a
default option and not the students preferred profession or perhaps nursing was a stepping stone
to another career. As a consequence, this background can negatively influence an individual’s
vulnerability, engagement, perception and occupational health (Rudman & Gustavson, 2012).
Conversely, undergraduate nursing students may already have well developed resilience prior
to commencement of their studies in nursing (Rudman & Gustavson, 2012). In a study by
Chamberlain et al. (2016 p.8) it was found that ‘the strongest predictors of resilience (in
nursing students) were attributed to dispositional mindfulness and its subset of acceptance’.
A major challenge to personal resilience relates to the nursing and hospital culture. While
professional socialization promises to ease transition when effectively scaffolded, such a
network can also be a threat, because of the stress of enculturation to ritualistic practices and
expectations (Boychuk Duchscher, 2008). Inevitably loss of empowerment and moral distress is
a likely result if pressured in this way to compromise care (Mooney, 2007b; Hamilton, 2005;
Boychuck Duchscher, 2004).
In response to these concerns, this study has garnered evidence based strategies reported to
assist with facilitating the safe transition of NGRNs and improve their willingness to remain in
the workforce. Bridging the gap between the undergraduate experience and the clinical world of
nursing is essential to reduce reality shock i.e. ‘a more accurate academic acknowledgement of
the clinical world of nursing may decrease new graduates’ sense of anxiety inherent within the
professional nursing role’ (Winfred, Melo & Myrick, 2009 p. 12). Hamilton (2005, p.76) describes
these disconnects as:
Discursive dissonances or differing constructions of the new graduate within institutional
discourses of education and health service. In educational discourse the graduate is
positioned as a critical thinking and knowing care giver . . . health service discourses
work to construct new graduates as functional, efficient, organizational operatives
providing a nursing service.
In accordance with this foreseeable assault on the NGRNs sense of self as a professional,
evidence suggests that a nurse’s self-concept fluctuates at the developmental stage as they
make the journey from student to graduate nurse (Pfaff, 2014). As a consequence, there are
implications for safe patient care and strategies should be directed towards enhancing the
undergraduate nurse’s self-confidence in preparation for transition (Cowin et al., 2006 p. 30).
NGRNs who lack confidence are less likely to assert themselves in an inter-professional
context, are fearful, easily intimidated, and patients may suffer as a result (Pfaff, 2014).
Confronting the realities of practice in the classroom will be of benefit to nursing students
before they become NGRNs (Shinners, 2016; Theisen, 2016). Students will likely have
misgivings from their engagement with the clinical practice environment as they may have
already experienced horizontal violence and pressures from a variety of sources (Hamilton,
2005). Hence, students should be eager to participate in conversations of this nature, to share
their stories and learn from each other. Possible conversations include:
The issues surrounding medication errors and reconciliation of mistakes, particularly when
students may have witnessed the mistakes of others (Cooper et al., 2015).
•The confounding problem of moral distress when as students they may have
been attempting to perform best practice and are discouraged from doing so
(LaSala & Bjarnason, 2010).
•The need to self-assess their own progress as in some work place environments it is
unlikely that such an opportunity will be provided to them on a regular basis (Parker et al.,
2014).
•The potential for the NGRN to jeopardize patient safety due to avoidance of shame
as was found by Malouf and West (2011).
Overall, there is a need to acknowledge the complexity of the nursing and health care culture in
a neutral classroom environment. Firstly, learning that their shared experiences are similar is
likely to be beneficial for students and secondly, provision of the opportunity to discuss possible
responses and rehearse solutions can be therapeutic and empowering (Goleman & Boyatzis,
2007; Shinners, Africa & Hawkes, 2016). As a consequence of this repositioning, students
would be afforded an extra layer of resilience so that, when they adopt the role of NGRN, they
recognize their struggles, not as a failure on their behalf, but a product of the many challenges
of the culture of nursing and health care environment.
Strengths and Limitations
The inclusion of a large number of journal articles in this review may be considered a strength.
All manuscripts were from peer reviewed journals. During thematic analysis, some themes were
well supported by a large number of references while others have less support due to the
paucity of research in that area. This does not mean that a theme should be discounted (Braun
& Clarke, 2006) with regard to recommended strategies or issues of concern for the NGRN. For
example, there was a relatively small number of references representing the theme ‘strategies
to manage moral distress and foster moral courage’. However, this theme was compelling,
considered relevant and therefore retained.
Conclusion
This study was a first step toward development of a comprehensive approach to undergraduate
education that prepares nursing students for transition to practice. Strategies recommended include
the need to: explore personal self-support, reflection and interpretive style; address social
intelligence and the need of the NGRN to fit into the organizational culture; understand the nature of
transition to practice; minimize horizontal violence; recognize and regulate emotions; manage moral
distress and foster moral courage; self-assess progress and performance. Enacting any one of these
strategies in professional practice is purported to be a significant determinant of “well- being”
outcomes for both the patient and NGRN. Interaction of two or more strategies would be even
more empowering. Further research is recommended to determine the most effective ways to
teach these strategies, to verify their effectiveness and identify possible further inclusions that
will improve the capacity of NGRNs to be successful during transition.
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