reality shock

Reality ShockThe Experience of Transition from Student Nurse to Registered Nurse

MDJ 4402 Nursing ManagementFa

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Prepared by:Jr Brian Hogan Paulus (matric no: 20570)

Lecturer:Mr Rekaya Vincent Balang

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Transition is a complicated process whereby many changes might occur at

once. The newly graduated nurse tries to juggle all the changes which may cause him or her to face reality shock. Discuss this issue. What are the strategies that

could ease this issue?

Assignment Topic3

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What is Reality Shock

How Reality Shock Emerges

Transition Stages during Reality Shock

Causes of Reality Shock

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Consequences of Reality Shock

Strategies to Reduce Reality Shock

Presentation Overview4

What is Reality Shock?

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Definition of TermsReality = The state of being realShock = A disturbance in the equilibrium or

permanence of something

(Merriam-Webster, 2012)

Hence generally,Reality Shock = The disturbance in the equilibrium of reality

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In nursing perspective:Reality shock is the shocking experience of new graduate nurses when they realise that the work situation for which they have prepared for DOES NOT exactly operate within the values and ideals that they had anticipated.

(Meleis, 2010)

This phenomenon emerges as the experience of transition from being a nursing student to a registered nurse.

(Duchscher, 2008)



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When a new graduate nurse starts working as a registered nurse, he or she would undergo experiences encompassing four main aspects:

1) Relationships2) Roles3) Responsibilities4) Knowledge

Expectations

REALITY SHOCK!!!

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Reality Expectations

Responsibilities

Roles

Relationships KnowledgeTransition from student

nurse to registered nurseTRANSITION

SHOCK

Slide 10

-Practice-Leadership/Delegation-Financial management-Home/Work balance

-Interdisciplinary/Intra-disciplinary-Sociocultural assimilation

-Changing roles and task-Family/friends/intimates -Critical decision making and clinical judgement expectations

-Developing personal identity

-Practice autonomy

-Life roles

-Professional roles -Role stress/strain

-Role confusion/ambivalence

-Role blurring

-Critical decision making and clinical judgement expectations

-Professional culture

-Roles and responsibilities

-Nursing as a profession

-Personal/professional self

-Intellectual/Practical/Theoretical/Tacit

-Relational dynamics

-Skills and task

-Performance expectations

-Transition experience

-Personal/professional relationships

-Organisational structure

-Intradisciplinary/interdisciplinary

relations -Social maturity

-Professional culture; peer support

-Life changes

-Developmental task

-Intergenerational dynamics

-Leadership and collaboration skills

Transition Shock Model (Duchscher, 2008)

Stages of Transition Shock are explained as a nurse’s orientation towards the new role as a registered nurse

Stages of Transition Shock

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TRANSITION TRANSITION

SHOCK

CRISIS

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DOING:• Learning• Performing• Concealing• Adjusting• Accommodating

BEING:• Searching• Examining• Doubting• Questioning• Revealing

KNOWING:• Separating• Recovering• Exploring• Critiquing• Accepting

ORIENTATION

Transition Stages Model (Duchscher, 2008)

Months of practice

1 2 3 4 5 6 7 8 and afterwards

Causes of Reality Shock

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(Bowles & Candela, 2005; Duchscher, 2008; Harwood, 2011; Hinton & Chirgwin, 2009; O’Shea & Kelly, 2006)

Causes of Reality shock

Unfamiliar environment

Different socio-cultural setting

Increased accountability

Knowledge and skills gap

Inadequate experience

Emotional Distress

Meet with new environment and

socio-cultural setting.

New environment different than

student environment.

The culture of the patient

e.g.: high demand

Work together. Need to accept

each other. Stressful.

(Bowles & Candela, 2005; Duchscher, 2008)

Unfamiliar Environment and Socio-cultural Setting

Increased Accountability

Unclear practice expectation

Professional accountability

Need to complete task given

Stressful

(Duchscher, 2008)

Theory-practice gap issue

Subject and assessment are different from what was learnt / out of date

Theory-based education and clinical placement are separated

Lack of critical thinking

(Hinton & Chirgwin, 2009)

Knowledge and Skills Gap

Inadequate Experience

Increasing of nursing students

Limited place for clinical placement

Student has short time for clinical

placement

Not enough time for adapt to clinical area

Lack of real clinical experience

(Harwood, 2011; Hinton & Chirgwin, 2009)

Emotional Distress

New environment

New social cultural

Lack of experience

Lack of knowledge

Increased accountability

Distress, frightening, low

self esteem

(O’Shea & Kelly, 2006)

Consequences of Reality Shock

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Negative Consequences

(Ambler, 1995; Banks & Bailey, 2010; Bowles & Candela, 2005; Cowan & Hengstberger-Sims, 2006; Bueno, 1995; Duchscher, 2008; Hodges et al., 2008; Horsburgh, 1989; Kelly, 1998; Kilstoff & Rochester, 2004; Stacey & Hardy, 2011; Walker, 1998)

High level of stress

Leave profession

Frustration and guilt

Subsequent powerlessness; fatigued, debilitating

Detrimental effects on nursing care; technical, task-driven, largely unsatisfying

Banks & Bailey, 2010; Duchsher, 2008; Halfer & Graf, 2006

Motivation of nurses

Positive Consequences

Job satisfaction

Evolution of a more mature, professional sense of self


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Transition Modules

Nurse Residency Programme

Manager’s support and mentorship

Transition Modules

• Integrating key components in real practical setting in the final modules of training.

• Developed by clinical education team of hospital and tutors in university.

• Initially implemented by universities in Canada with collaboration from local hospitals.

• Aimed to support new staff nurses during their first 6 months following qualification

Source: Broad, Walker, Boden & Barnes (2011)

Successful

transition

Prioritization of patient’s

care and confidence

issues especially medicines

management.

Planning and organization of patients’

care

Basic life support

Practical issues such as medical equipment

safety


Transition Modules: Highlights

Graduates

•Increase in confidence & competence in commencing their new role, they feel more positive

Employing hospital

•Employees more likely to remain in profession - more cost effective•Better contribution to patient’s care


Transition Modules: Outcome

• Start being implemented in Children Hospital Los Angeles and followed by another 35 Hospitals in States

• Lasting for about one year.• Group of 6 to 10 nurses meet monthly for a 4 hour session

in which they share ‘tales from bed side’ facilitated by an expert nurse.

• It help graduate nurses to: Solve problem that they are experiencing out in their units. Learn a concise way to give patient report to

doctor ,delegate tasks and think critically. Bond socially “Most of us were stressed but when we told our stories, we laughed & you

could feel the tension going out of the room. It helps you realize you are not alone”.

Source: Thrall, 2007

Nurse Residency Program

Nurse Residency Program... why hospitals are starting it?


Increase level of new graduate nurses’ preparedness to become staff nurse

Percentage of new graduate reporting education adequately preparing them to...Statement Percentage Provide direct care to 6 or more patients 22%Know when and how to call a physician 42%Synthesize data from multiple source in making decision 50%Delegate to other RNs and assistive personnel 32%Manage time, organize workload and prioritize tasks 47%Appropriately utilizing research finding in providing care 48%

Source: National Council of State Board of Nursing, Practice and Professional Issues Survey, Fall 2004 & 2006.

Nurse Residency ProgramPercentage of hospitals in States reporting new graduates ‘definitely’ prepared

to provide safe and effective careDiploma Bachelor Degree

47% 41%

Source: National Council of State Board of Nursing 2003 Employer Survey, 2004.

Turnover rate for new graduate nurses 12 month 24 monthBefore implementation of the program 36% 56%After implementation of the program 7% 12.6%

United States had started this program since 1999. Children Hospital Los Angeles had implemented the Nurse Residency Program and found out that from 1999 to 2007, the average turnover rate of graduates had dropped drastically.


Nurse Residency Program: Outcome• Nurses become better at asking the right questions, pulling together needed

data, realizing what fit and what doesn’t and where to find resource they need.

• Moreover, through this program, they are better equipped to start assignments in specialized unit such as critical care rather than start on medical-surgical unit and work their way into more complex care

What draw this program back?• Lack of time• Lack of experienced nurses to teach, mentor and

track the new graduate nurses.• Cost a lot- pay for facilitator & educator, for

graduate nurses during course time etc.



A good manager should: Be accessible Be visible Practice clear and transparent communication Enact evidence based practice Frequently check in with new graduates.

Supports includes:- Formal orientation - Arrange work scheduled in a way that it adapted so that new

graduates are supported by the experienced staffs.

Manager’s Support and Mentorship

Source: Morrow, 2008

• Mentor can share their experience about some real life problem and stress mgmt with the new graduates such as how to promote effective when working a night schedule .

• Is a win-win relationship where senior staff nurse also improve leadership skills, professional relationship, learn problem solving skills which lead to job satisfaction

• Includes:i. introduction to practice environmentii. overt and covert culture

Source: Alspach, 2006; Morrow, 2008

Mentorship

Practice environment

Personalize team by creating “who we are” bulletin board

Experience nurses need to demonstrate maturity with conflict management.

Exp: ‘teachable moment’ vs. talking behind graduate nurse’s back

Inside joke may lead to unintended misinterpretation by the graduates

Source: Dracup & Bryan-Brown, 2004; Morrow 2008

Mentorship includes...

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ConclusionNew nurses face great challenges when they undergo the

transition from student nurse to registered nurse. The challenges arise due to the reality which differs from the new

graduate nurses’ expectation.

When the reality is different, the situation demands adaptation. The adaptation is seen as the new graduate nurses’ orientation

to the reality.

Different nurses have different level of ability to adapt, which requires time varying from a nurse to another.

Successful adaptation could produce positive outcome to the nurses whilst failure to adapt causes negative impacts to nurses

and nursing profession.

To solve the negative impact caused by reality shock, new graduate nurses needs to prepare themselves physically,

intellectually, emotionally, and socioculturally.

37Slides prepared by Jr Brian Hogan

References

Ambler, N. (1995). The beginning practitioner: 1st year RN adaptation to the workplace. Paper read at Conference Proceedings Research for Practice, at Newcastle University.

Banks, Z. M., & Bailey, J. H. (2010). Career motivation in newly licensed registered nurses: What makes them remain. The Qualitative Report, 15(6), 1489-1503. Retrieved from http://www.nova.edu/ssss/QR/QR15-6/banks.pdf

Bowles C. & Candela L. (2005). First job experiences of recent RN graduates. Journal of Nursing Administration, 35(3), 130–137.

Broad, P., Walker, J., Boden, R., & Barnes, A. (2011). Developing a ‘model of transition’ prior to preceptorship. British Journal of Nursing, 20, 20.

Bueno, D. (1995). Ready, willing, able? Staff competence in workplace design. Journal of Nursing Administration, 22, 14-16.

Cowan, L. S. & Hengstberger-Sims, C. (2006). New graduate nurse self-concept and retention: a longitudinal study. International journal of nursing studies, 46, 59-70 doi:

10.1016/j.inurstu.2005.03.004.Duchscher, J. B. (2008). Transition shock: The initial stage of role adaptation for newly graduated

Registered Nurses. Journal of Advanced Nursing, 65(5), 1-11. doi: 10.1111/j.1365-2648.2008.04898.x

Halfer, D. & Graf, E. (2006). Graduate nurse perceptions of the work experience. Nursing economics, 24(3), 150-155.

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References

Harwood, M. (2011). Transition shock: Hitting the ground running. Nuritinga, 10(10), 1-11. Retrieved from http://www.utas.edu.au/__data/assets/pdf_file/0007/156661/M_ Harwood.pdf

Hodges, H. F., Keeley, A. C. & Troyan, P.J. (2008). Professional resilience in Baccalaureate-prepared acute care nurses: First steps. Nursing Ethics, 14 (6), 716-740.Horsburgh, M. (1989). Graduate nurses’ adjustment to initial employment: Natural field work.

Journal of Advanced Nursing, 14, 610-617.Kelly, B. (1998). Preserving moral integrity: A follow-up study with new graduate nurses. Journal

of Advanced Nursing, 28, 1134-45.Kilstoff, K., & Rochester, S. F. (2004). Hitting the floor running: Transitional experiences of

graduates previously trained as enrolled nurses. Australian Journal of Advanced Nursing, 22(I), 13-17.

Morrow, S. (2009). New graduate transitions: leaving the nest, joining the flight. Journal of Nursing Management, 17, 278-287.

Stacey, G. & Hardy, P. (2011). Challenging the shock of reality through digital storytelling. Nursing education in practice, 11, 159-164 doi:10.1016/j.nepr.2010.08.003.

Thrall, T. H. (2007). Shock absorbers. Hospitals & Health Networks, 81(6), 60.Walker, W. (1998). The transition to registered nurse: The experience of a group of New Zealand

graduates. Nursing Praxis in New Zealand, 13(2), 36-43.

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