Duchscher Article

8/12/2019 Duchscher Article

1/11441The Journal of Continuing Education in Nursing October 2008 Vol 39, No 10

Earn 2.3 Contact Hours

cneARTICLE

The current global shortage of nurses is unprecedent-ed, with demands for full-time nursing profession-als growing faster than the rate at which new nurses aregraduating (Barney, 2002; Purnell, Horner, Gonzalez,& Westman, 2001; Shields, 2004). The challenge of re-

placing nurses who have left the workplace and a desirefor knowledge about the resources required to supportthose just entering it are motivating health care institu-tions and nursing leaders to explore exactly what con-stitutes a quality work environment (Buerhaus et al.,2007; Coomber & Barriball, 2006; Lin & Liang, 2007;May, Bazzoll, & Gerland, 2006). Growing rates of sea-soned nurse attrition are resulting in the replacementof highly competent and experienced practitioners withnewly graduated nurses who have neither the practiceexpertise nor the confidence to navigate a clinical envi-ronment burdened by escalating levels of patient acuityand increasing workload (Roberts & Farrell, 2003; Tay-

lor, 2002). Compounding this human resource man-agement crisis is evidence of a disorienting, discourag-ing, and exhausting initial work experience for youngnurses that is resulting in high levels of burnout amongthem within the first 18 months of professional practice(Cho, Laschinger, & Wong, 2006; Laschinger & Leiter,2006).

Newly graduated nurses are entering the work force

and finding that they have neither the practice expertise

nor the confidence to navigate what has become a high-

ly dynamic and intense clinical environment burdened by

escalating levels of patient acuity and nursing workload.

This research used qualitative methods to build on and

mature aspects of the new nurses transition experience

into acute care. The theory of transition presented in

this article incorporates a journey of becoming where

new nursing graduates progressed through the stages

of doing, being, and knowing. The whole of this journey

encompassed ordered processes that included anticipat-

ing, learning, performing, concealing, adjusting, question-

ing, revealing, separating, rediscovering, exploring, and

engaging. Although this journey was by no means linear

or prescriptive nor always strictly progressive, it was evo-

lutionary and ultimately transformative for all participants.

The intense and dynamic transition experience for these

newly graduated nurses should inspire educational and ser-

vice institutions to provide preparatory education on

transition as well as extended, sequential, and structured

orientation and mentoring programs that bridge senior

students expectations of professional work life with thereality of employment.

J Contin Educ Nurs2008;39(10):441-450.

abstract

A Process of Becoming: The Stages of NewNursing Graduate Professional Role TransitionJudy Boychuk Duchscher, RN, BScN, MN, PhD

Dr. Boychuk Duchscher is Facilitator, Scholarly Projects and Pro-grams, SIAST Nursing Division, Saskatoon, Saskatchewan, Canada.

The author discloses that she has no significant financial interests inany product or class of products discussed directly or indirectly in thisactivity, including research support.

The author acknowledges Dr. Joanne Profetto-McGrath and Dr.Olive Yonge of the University of Alberta Faculty of Nursing for theircontinued support and guidance during her recent doctoral study. Fur-ther to this, sincere appreciation is extended to the Social Science andHumanities Research Council (SSHRC) for the Canada GraduateScholarship that permitted the depth and breadth of this authors studyduring the past 6 years. Finally, the author is grateful to the SIASTNursing Division faculty and deans, who have provided her with out-standing support to conduct her research and writing during the past10 years.

Address correspondence to Judy Boychuk Duchscher, RN, BScN,MN, PhD, SIAST Nursing Division, 1130 Idywyld Drive, Saskatoon,SK S7K 3R5, Canada.


2/11442 The Journal of Continuing Education in Nursing October 2008 Vol 39, No 1


cneARTICLE

This article presents the results of a 10-year evolvingprogram of research on the new graduate transition ex-perience, the most recent study having been conductedas part of the authors doctoral work. This latest body

of work was undertaken with the intent to evolve a sub-stantive theory of role transition to professional nursingpractice for newly graduated nurses. What emerged wasa staged experience of transition that occurs during theinitial 12 months of the graduates introduction to pro-fessional practice (Figure). Inherent within this transi-tion are processes that move these novice practitionersthrough increasing levels of knowledge and broadeningscopes of practice, and contribute to the ongoing devel-opment of their personal and professional selves. Thistheory of transition stages is intended to be used as aguide by clinical educators, unit managers, and hospitaladministrators who are recruiting, orienting, mentor-ing, and seeking to successfully integrate new nursesinto their workplace.

BACKGROUNDThe newly graduated nurses experience of transition

when entering professional practice, although not com-pletely separate from the constructs of socialization andprofessionalization, is differentiated here as the processof making a significant adjustment to changing personaland professional roles at the start of ones nursing career.Understood in the context of this research, transition fornewly graduated nurses consists of a nonlinear experi-

ence that moves them through personal and professional,intellectual and emotive, and skill and role relationshipchanges and contains within it experiences, meanings,and expectations. Although it is reasonable to presumean individualized transition experience for the newlygraduated nurse, the first 12 months of work experienceencompasses a complex but relatively predictable arrayof emotional, intellectual, physical, sociocultural, anddevelopmental issues that in turn feed a progressive andsequential pattern of personal and professional evolu-tion.

The basis for this theory of transition arises out of

four qualitative studies spanning 10 years (Cowin &Hengstberger-Sims, 2006; Duchscher, 2001, 2003b,2007) and the authors extensive study of new gradu-ate transition and her work in establishing a nationalnon-profit organization of support resources for newlygraduated nurses (www.nursingthefuture.ca). The finalstudy, which culminated in the conceptualization of thetransition stages theory presented here, employed a ge-neric qualitative approach of interpretive inquiry, usingfoundational knowledge on the newly graduated nursesintroduction to the workplace to frame an exploration

of the process of transition that occurs during the fir12 months of practice. Fourteen female graduates fromthe same 4-year baccalaureate undergraduate nursinprogram were selected from two major cities in Canad

Research strategies included a demographic survey the start of the research; six face-to-face interviews at 3, 6, 9, 12, and 18 months followed, in the initial twinstances, by focus groups with participants from thsecond major city; pre-interview questionnaires requesing the completion of a process-revealing exercise (i.eletter writing, collage construction, or picture drawingmonthly journals; and ongoing e-mail communicatiowith all participants during the 18 months.

CONCEPTUAL FRAMEWORK OF TRANSITIONSTAGES

Transitions have been defined as passages or movements from one state, condition, or place to anothewhich can produce profound alterations in the lives oindividuals and their significant others and have impotant implications for well-being and health (Schumacher & Meleis, 1994, p. 119). The process of transitioto professional practice among nursing graduates habeen reported most notably by Kramer (1974). Thprocess evolves in a fairly predictable manner from thhoneymoon phase, where graduates are excited anexhilarated; through a shocking assault on their professional values that leaves them disoriented and disillusioned; and to the recovery and resolution phase

marked by a return of a sense of balance (Kramer &Schmalenberg, 1978).

Dearmun (2000), Duchscher (2001), Ellerton anGregor (2003), and Kelly (1998) provide the next levof formalized analysis of newly graduated nurses transition stages that informed this authors research. Remarkably similar thematic conclusions were presentethat reflected the prior work of Bridges (1991), Krame(1974), and Benner (1984). Dearmun and Duchscheboth claimed that the initial 3 months of newly graduated nurses transition is consumed by an adjustmento new roles and responsibilities, an acceptance of th

differences between the theoretical orientation of theeducation and the practical focus of their professionawork, and their integration into an environment thaemphasizes teamwork as opposed to individually basecare provision. A significant change in the graduateperception of their experience is noted at approximately 5 to 7 months, propelling them to yet another stagof greater consolidation and meaning making (Duchscher). In all the research reviewed, varying degrees oattention were paid to the emotional impact of the transition on newly graduated nurses and its significance t




cneARTICLE

newly graduated nurses ability to advance through thestages. With the exception of some of Kramers workin the 1960s, no studies mentioned formally acknowl-edged the significance of either developmental or so-ciocultural origins to or physical expressions of roletransition stress for newly graduated nurses. Finally,few studies since Kramers have distilled out the nu-ances of the transition experience at various stages or

have sought to clarify the relationship of the stages ofgrowth and change in the newly graduated nurse to thepassage of time.

Several authors have more peripherally enhancedthe understanding of the phases and stages of transi-tion for the newly graduated nurse (Brown, 1999;Casey, Fink, Krugman, & Propst, 2004; Chang &Hancock, 2003; Goh & Watt, 2003; Ross & Clifford,2002; Schoessler & Waldo, 2006; Tiffany, 1992). Issuescommonly cited as troublesome for newly graduatednurses at various points in time throughout the initial

12 months relate to a lack of clinical knowledge andconfidence in skill performance, relationships withcolleagues, workload demands, organization and pri-oritization as they relate to decision making and directcare judgments, and communicating with physicians.Although many of these studies measured or identifiedparticular concerns at points in time (e.g., scheduledtesting by instrument, interview, or focus group), few

gave insight into what aspects precipitated their occur-rence or supported their presence, precisely when theissues originated, or what factors may have impededor mediated the resolution of those issues. The intentof this final study in the authors grounded theory re-search program was to examine further, build on, andmature aspects of the newly graduated nurses transi-tion experience into acute care such that an accurateoverall representation of this experience and the pro-cesses encompassed within could be confidently intro-duced into the scholarly community.

Figure. The Stages of Transition Theory.




cneARTICLE

STAGES OF TRANSITIONThe initial 12 months of transition to professional

acute care practice for the graduates in this research wasa process of becoming. Both a personal and a profes-

sional journey, participants evolved through the stagesof doing, being, and knowing. The whole of this journeyencompassed ordered processes that included anticipat-ing, learning, performing, concealing, adjusting, ques-tioning, revealing, separating, rediscovering, exploring,and engaging. Although this journey was by no meanslinear or prescriptive nor always strictly progressive, itwas evolutionary and ultimately transformative for allparticipants. Further, data manifested ongoing, but tran-sient, regressions precipitated by the introduction ofnew events, relational circumstances, and unfamiliar orcomplex practice situations or contexts into the gradu-ates assumed location on the transition continuum thatis represented by the stages theory presented here.

Doing

The initial period of professional role transition forthese acute care nurses encompassed approximately thefirst 3 to 4 months of the study. All participants under-went a period of orientation prior to study commence-ment and were working more than 50% maximumhours on varying acute adult and pediatric medical sur-gical units in different hospitals. One worked in a neo-natal intensive care unit. The majority had been hiredinto temporary part-time or casual positions, but were

working full-time hours. Thirty percent of the partici-pants were shared (e.g., float position) between two andfive different units on an ongoing basis. None had yetwritten their registered nurse qualifying examination;thus, all were working under the probationary title ofgraduate nurse. The initial transition from a structured,relatively predictable life into a new set of expectationsand responsibilities posed numerous challenges to boththeir personal and professional selves. Although ini-tially excited to manage the transition from student toprofessionally practicing nurse, the participants quicklyrealized that they were unprepared for the responsibility

and the functional workload of their new roles:Its strange. I dont really feel like I am finished school.Like I walked to work one morning and as I was walk-ing, I was thinking, Im getting paid to do this, becauseits like I was still in school. And then, within my orien-tation week I was told that the staff had just run off thisnurse who wasnt doing very well. They told me thatthey had made it so miserable for her that she wouldleave . . . and I think they were proud of itthat theyhad gotten rid of her. I think its maybe to maintain qual-ity control, but its definitely one of my fears that I wontbe accepted. That if I am failing, they wont come along-side me, but will show me the door.

The majority of these newly graduated nurses entered their professional transition with expectationand anticipations that were more idealistic than reaistic. They often blamed the disparities between wha

they had anticipated regarding their roles as nurses anwhat they were being expected to do in the real worlon lack of educational preparation. When asked, nonof the participants at this stage considered the culpabiity of their workplaces in failing to prepare them for ogradually introduce them to the roles and responsibilties of a fully practicing nurse. They were surprised athe intense and heavy workload of ward nurses, struggled with the non-nursing duties they were expected tassume, and ultimately expressed disappointment at thlow value placed on their contribution to assigned uniand nursings contribution to institutional operationin general.

This first stage of entry into professional practicwas marked by a tremendous intensity, range, and fluctuation of emotions as graduates worked through thprocesses of discovering, learning, performing, concealing, adjusting, and accommodating. Within several weeks of being hired, these novices were affordefull patient loads equal to those of their senior nursincounterparts, but without reasonable access to expercounsel or practice support. None of the participantin this study was formally mentored, and the majoritwent from buddy experiences to full responsibilitwithout graduated progression.

Their discovery that all was not as they had expecteit to be sent these newly graduated nurses into a flurrof learning and subsequent performing. Understandinwhat was expected of them, doing it well, and completing their tasks on time were their primary concerns. Thfocus became clearer upon hearing their stories of being chastised by senior coworkers on the unit or calleat home after their shift because they had forgotten tdo something. Uncertain who they could trust and driven by a need to belong, these graduates went to grealengths to disguise their emotions from colleagues anworked to conceal any feelings of inadequacy.

Because so much of what the newly graduated nurses were experiencing was new to them, the functionlearning curve that dominated this stage of transitiowas steep. As a result, the solid professional identitdeveloped by many by the end of their undergraduatyears fractured under the weight of performance anxety and self-doubt. These graduates felt stressed abouabsolutely everything. The new practitioners adequatand sometimes advanced entry-level skill and knowledgwere constantly challenged by their wavering confidenctheir limited experience with the application of that ski




cneARTICLE

and knowledge, and a lack of predictability of and famil-iarity with the many variations in clinical contexts. Therelentless requests to assist with or perform proceduresfor which they had little or no reference caused signifi-

cant levels of anxiety. These situations posed a high levelof risk to graduates of being exposed as incompetent andsubsequently reducing their credibility in the eyes oftheir colleagues.

During this initial stage of their transition, the newnurses felt able to reasonably manage a workload con-sisting of a nurse to patient ratio of less than 1 to 8 butwere often left caring for anywhere between 8 and 16adult patients without consistent support from anotherlicensed practical nurse or registered nurse. High levelsof stress were associated with caring for patients whowere clinically unstable; being expected to multitask(i.e., answering phones, speaking with physicians, pro-cessing orders, and dealing with multiple patient andfamily issues concurrently) while providing direct careto patients (i.e., starting intravenous therapy, dispensingmedications, and performing dressing changes); caringfor patients who were critically ill or dying; or dealingwith families who had numerous questions or demands.Many examples were given of graduates whose intensefocus on every job detail prevented them from hearingor seeing what was happening around them. As a result,graduates universally expressed anxieties around miss-ing something or inadvertently and unintentionallybringing harm to someone under their care because of

their ignorance or inexperience.Not uncommonly, participants descriptions of clini-

cal situations exposed a prescriptive approach to theirthinking. One participant suggested that this early prac-tical application of knowledge was akin to being in aprivate little bubble and things are going on all aroundme and I cannot hear them, I cannot see them. Thelimits to their problem solving and clinical judgmentwere not surprising because they had never experiencedmany of the scenarios to which they were being exposed.Strategies to manage complex clinical scenarios seemedunavailable to their minds, which were consumed with

completing tasks and routines within the rigid timeframes imposed by the structure of the units where theyworked. It was understood that failure to adjust to orcomply with existing routines could garner exclusiveattention, an outcome that conflicted with the develop-mental task of fitting in to their dominant professionalculture.

Contributing to their stress was the expectation thatthey would delegate appropriate tasks and responsibili-ties to other licensed and non-licensed personnel, manyof whom were older and advanced in clinical experience

and practice seniority. Participants also found them-selves frustrated by what they perceived as archaic waysof thinking about nursing by some senior colleagues,and expressed disappointment regarding the rigid and

distracting allocation of non-nursing tasks. Althoughthese graduates felt the immediate need to accommodatewhat was being practiced without asking why, they lateridentified these issues as primary factors contributingto their lack of professional fulfillment in an acute carenursing role:

I was so focused on knowing the routine, knowing whatIm doing, getting things done, knowing the way dif-ferent nurses like things done, knowing where I fit in,what Im supposed to be doing, when Im supposed tobe doing it. I had total tunnel vision. I was just focusedon getting the job done and getting out of there on time.Then I would go home and I would feel guilty for notbeing more.

During this stage of transition, the graduates overallenergy was divided between the demanding professionaladjustments cited above and the sociocultural and devel-opmental changes occurring in their broader lives. Thesewomen experienced changes such as new living arrange-ments, terminated or advanced intimate relationships,and the acquisition of unprecedented debt through thepurchase of cars and homes, all serving as both excit-ing distractions and unexpected burdens. Concurrently,these normally high-spirited young nurses were adjust-ing to intimidating levels of clinical responsibility, navi-gating new professional associations while struggling

to let go of long-standing personal relationships, seek-ing acceptance into a tradition-bound and hierarchicalnursing culture, and adjusting to the physical demandsof intensive, alternating, and sometimes unpredictableor inflexible day or night shift schedules. It was in thecontext of undergoing this tremendous inventory ofdevelopmental change that these nurses made advancedclinical judgments and practice decisions for which theyfelt minimally qualified and completely responsible.They were exceptionally hard on themselves when theyfelt they had failed to identify or appropriately intervenein a changing clinical situation regardless of competing

demands. Despite the fact that many of the situations inwhich they were placed were beyond their intellectual orpractical capability, their behavior was consistently self-deprecating.

Being

The next 4 to 5 months of the newly graduated nurs-es postorientation transition experience was marked bya consistent and rapid advancement in their thinking,knowledge level, and skill competency. Concurrently,this stage sparked disconcerting doubt in the participants




cneARTICLE

regarding their professional identity by challenging pre-graduate notions of nursing and exposing the inconsis-tencies and inadequacies in the health care system. Oneparticipant articulated this as follows:

The reason Im finding this part of the transition to bethe most difficult is because the excitement about beingdone and the shock that I was in has worn off. I feel asthough Im on a raft that is drifting farther and fartheraway from the shore (my safety net of being a studentor a new grad). And Im floating toward an island wherethe experienced nurses are, but I keep losing sight ofthem due to all the waves.

The high degree of frustration and subsequent en-ergy consumption that characterized the prior stageof their transition continued at a slower, but relent-less pace. To cope with the drain on their resources,many of the newly graduated nurses sought refuge intheir personal lives, separating themselves from theirwork environment (e.g., refusing overtime) and put-ting distance between themselves and their colleagues(e.g., choosing to forego staff functions). Fundamentalto this stage was an increased awareness of themselvesprofessionally, an exploration of the role of the nurserelative to other health care professionals, and a funda-mental search for balance between their personal andprofessional lives. During the initial half of this stage,the participants became increasingly comfortable withtheir roles and responsibilities as nurses. This comfortpermitted them to begin a concerted examination of theunderlying rationale for nursing and medical interven-

tions and the appropriateness and effectiveness of thehealth care system. Scrutinizing the practice contextand its relationship to the graduates professional roleaspirations took on more importance during the finalstage of their transition. During the course of this sec-ond stage, the newly graduated nurses would disengage,question, search, reveal, recover, accept, and ultimatelyreengage in their chosen career; the difference was thistime it was on their terms.

As one participant suggested, the initial segment ofthis second stage found these nurses caught up in aturn. There was awareness that something was differ-

ent, but they would spend several months strugglingwith the changes brought about by their commitmentto become a real nurse. Many questioned why theyhad left the comforts of their established school rou-tine only to expose themselves to a daily onslaught ofdaunting responsibility that left them feeling perpetu-ally incompetent, inadequate, exhausted, disappointed,devalued, frustrated, and powerless. This downwardspiral motivated a protective withdrawal from theirsurroundings as they attempted to recover a sense ofcontrol over their lives. They expressed a strong de-

sire for clinical placements that offered stable patiensituations, and several of the newly graduated nursechanged to casual employment status so they coulchoose the work hours required. Most had tired of th

constant newness and were looking to escape the barage of learning, growing, and changing; they wanted tbe surrounded by familiarity, consistency, and predicability.

Participants sense of self-trust was tenuous durinthe initial phase of this stage. Many sought validatiofor their decision making and clinical judgments fromsenior coworkers whose level of practice they respected and admired. Unlike the first transition stage, wherthey required more prescriptive directives about whashould be done in particular clinical situations, participants were now expressing a desire for clarificatioand confirmation of their own thoughts and actionKnowing they could make decisions and implemennursing actions that were not only safe and approprate but also astute was important for their confidencDuring the initial several months of this second staggraduates were placed in leadership positions (e.g., puin charge of units or students or made responsible foorienting new staff) that they consistently deemed ainappropriate and unsafe. A disturbing finding was thfrequency with which they were placed in clinical situations beyond their clinical competence, cognitive, oexperiential comfort level. More than 30% of particpants with less than 5 months of experience were eithe

requested to go to or assigned shifts in an observatiounit. All of them expressed significant discomfort athese requests, although the majority either felt too newto make demands about their placements or interpretethe appeals for advanced responsibility as a statemenof confidence in their abilities, making it difficult to refuse the requests.

The start of this stage was delicate for the newlgraduated nurses as the desires to hold on and to let gwere equally strong. The newly graduated nurses identified overly vigilant supervision of their practice as display of doubt in their abilities, but feelings of aban

donment when left without experienced nurses to reacout to in unfamiliar, unexpected, or unstable situationThe peak of this struggle occurred for most around to 7 months when a crisis of confidence, mitigated bthe intersection of insecurities regarding their practiccompetency and their fear of failing their patients, coleagues, and themselves, motivated a renewed commiment to maturing their practice that would carry themthrough the next several months. During the course othe remainder of the second stage, the newly graduated nurses found more middle ground, claiming les




cneARTICLE

often that the good days are great and the bad daysare horrible. An increasingly moderate perspective ontheir professional experiences became evident. Havingbeen previously frustrated by their perceived lack of

progress, the graduates relaxed into a more comfort-able space that permitted the mild angst that came withwhat they did not know to coexist with the growingconfidence in what they did know.

An essential element to the newly graduated nursesrecovery during the latter part of this stage was reac-quainting themselves with personal aspirations that hadbeen subverted for professional growth. Less cognitive,physical, and emotional energy was needed to managethe now familiar nursing procedures and clinical situa-tions. Participants required less energy to debrief aboutwork, affording them more time to adjust to and acceptthe changes to their personal and work life schedules andenjoy their new-found liberation. Within several months(approximately 6 to 8 months postorientation), a rejuve-nated spirit reawakened and inspired them to seek outchallenges to their thinking, put themselves in new andunfamiliar practice situations, and plan long-term careergoals.

Knowing

The final stage of the newly graduated nurses initial12 months of practice was focused on achieving a separ-ateness that both distinguished them from the establishedpractitioners around them and permitted them to reunite

with their larger community as professionals. Dialoguerevealed that the majority of graduates harbored appre-hension about moving out of the learner role into onethey perceived held greater expectations and a reducedmargin of error. During this final stage of their profes-sional role transition, newly graduated nurses contin-ued the recovery they had started during their secondstage. Some participants experienced a shift in primarysupportive relationships from non-nursing pregraduatefriends and family members to coworkers and nursingcolleagues, whereas others were crystallizing intimaterelationships through engagements and weddings. There

was a sense, particularly during the initial months of thisfinal stage, that the graduates just wanted to get up andgo to work and come home to my life . . . my eyes andears are open, but my mouth is closed. Especially to-ward the latter half of this stage, an increased amount oftime was spent exploring and critiquing their new pro-fessional landscape. Also, graduates began taking noticeof the more troubling aspects of their sociocultural andpolitical environments.

Although participants identified themselves as onlymoderately stressed at both the 9- and 12-month study

time periods, the factors contributing to their stresslevel changed from their individual capacity to copewith their roles and responsibilities to frustrations indealing with the system (i.e., the institution or health

care) at large. An overwhelming majority of partici-pants offered descriptions of nurses being at the bot-tom of the hierarchy of authority and power. A grow-ing discontent with what they perceived as professionaldevaluing would culminate in yet another, althoughmuch less dramatic, reduction in their momentum. Formany, this served as the point of origin in their searchfor professional fulfillment outside of their acute carebedside role.

By the 12-month marker, all graduates had reacheda relatively stable level of comfort and confidence withtheir roles, responsibilities, and routines. Many spenttime comparing their practical skill level and cogni-tive prowess with that of the newest graduates enteringtheir clinical environments, making mention of the dif-ferences they noticed between themselves and these newcolleagues:

Perhaps I noticed such a difference because I reportedoff to a new grad. And the contrast between our reac-tions is what made me realize I have changed. I watchedas her eyes became bigger and bigger as I gave report.She almost started panicking before I was even done andstated she felt really overwhelmed. I remember exactlyhow she felt, but I was surprised (and relieved) that I nolonger felt this way about work.

Being able to answer questions rather than simply

ask them and assist others with their workloads wereboth identified as notable signs of their progress. Sev-eral participants suggested that these changes were at-tributed to advancements in their organization and pri-oritization, whereas others claimed that all of a sudden,you look back and its like how did I get from there tohere, because its gradual and it happens without yourrealizing it. Another participant stated, You know, itcould be exactly the same scenarios, but my ability tocope has changed, illuminating the grounded perspec-tive expressed by the whole of the study group at thisfinal stage.

DISCUSSION AND RECOMMENDATIONS

Bridges (1991) claimed that prior to embarking on atransitional process, individuals must recognize in them-selves a need for change. This defining moment for thenewly graduated nurses of this final study was dually de-velopmental, because many of them were experiencingtotal and independent responsibility for the first time,and situational as they explored the new dimensions oftheir professional roles separate from being students.These young professionals generally have limited prac-


8/11




cneARTICLE

larly during the initial several months of the second stageof transition (4 to 6 months), to recover their sense ofbalance and restore their depleted energy reserves. En-couraging graduates to pursue personal enhancement

activities and settle their lives outside of nursing willset the stage for a more long-term commitment by thegraduates to their work environment.

During the final stage of transition (8 to 12 months),newly graduated nurses maintain a variable tensionbetween a contented enjoyment of their work and theinherent tendency toward mobility and career advance-ment that is characteristic of this generation (Duchscher& Cowin, 2004). Mentors and managers working withnewly graduated nurses would be well served to joinwith them in formulating a 2- and 5-year career trajec-tory that addresses their most immediate plans and sup-ports, both educationally and organizationally, theirprojected professional aspirations. It is in this stage thatnewly graduated nurses seek to establish a separatenessthat both distinguishes them from and allows them tounite with the practitioners in their larger communityand develop a sense of agency that permits them tosee the potential for and process of making sustainablechange within a bureaucratic system (Benner, Tanner, &Chesla, 1996; Pask, 2003). The awakening of this insightshould be part of the evolving relationship between amentor and a senior graduate and considered a healthy,essential step in the newly graduated nurses sociodevel-opmental maturity.

New graduates will likely express some discontent-ment about the encroachment of work on their per-sonal lives, a concern that may be exacerbated if theydid not receive reasonable support early in their transi-tion. Experiences of being restrained in the enactmentof their professional role, growing frustration with theapparent complicity of their colleagues to the impro-prieties of the practice environment, and the feelings ofpowerlessness that these issues may engender in newlygraduate nurses should be considered a natural part oftheir professional development. It is possible that thedeleterious influence of these factors on newly gradu-

ated nurses sense of agency may be muted by oppor-tunities to actualize some form of change in the unitor the institution during the latter half of this stage (10to 12 months). Having an institutional or region-wide,rather than a unit-based, approach to advancing the ca-reer pathway of newly graduated nurses and being opento challenge and change at all levels of the organizationare not only desirable attributes of the contemporaryworkplace, but may well determine the recruitment andretention capacity of all future health human resourceinstitutions.

REFERENCESBarney, S. M. (2002). The nursing shortage: Why is it happening?Jour-

nal of Healthcare Management, 47(3), 153-155.Benner, P. (1982). From novice to expert.American Journal of Nursing,

82(3), 402-407.Benner, P. (1984).From novice to expert: Excellence and power in clini-

cal nursing practice.Menlo Park, CA: Addison-Wesley.Benner, P. A., Tanner, C. A., & Chesla, C. A. (1996). Expertise in

nursing practice: Caring, clinical judgment, and ethics. New York:Springer.

Bridges, W. (1991). Managing transitions: Making the most of change.Reading, MA: Addison-Wesley.

Brown, P. L. (1999). Graduate nurses: What do they expect? KansasNurse, 74(5), 4-5.

Buerhaus, P. I., Donelan, K., Ulrich, B. T., Norman, L., DesRoches, C.,& Dittus, R. (2007). Impact of the nurse shortage on hospital pa-

tient care: Comparative perspectives. Health Affairs, 6(3), 853-862.Casey, K., Fink, R., Krugman, M., & Propst, J. (2004). The graduatenurse experience. Journal of Nursing Administration, 34(6), 303-311.

Chang, E., & Hancock, K. (2003). Role stress and role ambiguity innew nursing graduates in Australia.Nursing and Health Sciences,5(2), 155-163.

Cho, J., Laschinger, H. K. S., & Wong, C. (2006). Workplace empow-erment, work engagement and organizational commitment of newgraduate nurses.Nursing Leadership, 19(3), 43-60.

Coomber, B., & Barriball, K. L. (2006). Impact of job satisfaction com-ponents on intent to leave and turnover for hospital-based nurses:A review of the research literature. International Journal of Nurs-

key points

Role TransitionDuchscher, J. B. (2008). A Process of Becoming: The Stages of

New Nursing Graduate Professional Role Transition. The Jour-nal of Continuing Education in Nursing, 39(10), 441-450.

1 The experience of transition for the new graduate entering

professional practice is distinguished here as the process of

making a significant adjustment to changing personal and pro-

fessional roles at the start of ones nursing career. Although

not explicit, the period of time during which the initial transition

to professional practice in nursing is generally thought to oc-

cur encompasses the first 12 months as a graduate and then

registered nurse.

2 The initial 12 months of transition to professional acute care

practice for graduates is a process of becoming. Both a per-

sonal and a professional journey, participants evolve through

three stages identified here as doing, being, and knowing.

3 The Stages of Transition Theory suggests that allowing gradu-

ates time to adjust to what is within a context of support that

allows them to develop their thinking and practice expertise

will assist them to move through the stages of professional

role transition.



ing Studies, 44(2), 297-314.Cowin, L., & Duchscher, J. E. B. (2007). Transitional programs. In E.

Chang & J. Daly (Eds.), Transitions in nursing:Preparing for pro-fessional practice(2nd ed.). Australia: Elsevier.

Cowin, L. S., & Hengstberger-Sims, C. (2006). New graduate nurse

self-concept and retention: A longitudinal survey. InternationalJournal of Nursing Studies, 43, 59-70.Dearmun, A. K. (2000). Supporting newly qualified staff nurses: The

lecturer practitioner contribution. Journal of Nursing Manage-ment, 8, 159-165.

Duchscher, J. E. B. (2001). Out in the real world: Newly graduatednurses in acute care speak out.Journal of Nursing Administration,31(9), 426-439.

Duchscher, J. E. B. (2003a). Critical thinking: Perceptions of newlygraduated female baccalaureate nurses.Journal of Nursing Educa-tion, 42(1), 1-12.

Duchscher, J. E. B. (2003b). Employing nursing graduates in emer-gency: A qualitative exploration of the integration of newly gradu-ated registered nurses into an emergency department. Unpublishedmanuscript.

Duchscher, J. E. B. (2007). Professional role transition into acute-careby newly graduated baccalaureate female registered nurses. Un-published doctoral dissertation, Edmonton, Alberta, Canada.

Duchscher, J. E. B., & Cowin, L. (2004). Multigenerational nurses inthe workplace. Journal of Nursing Administration, 34(11), 493-501.

Ellerton, M., & Gregor, F. (2003). A study of transition: The new nursegraduate at 3 months. The Journal of Continuing Education inNursing, 34(3), 103-107.

Ferguson, L. M., & Day, R. A. (2004). Supporting new nurses in evi-dence-based practice. Journal of Nursing Administration, 34(11),490-492.

Goh, K., & Watt, E. (2003). From dependent on to depended on:The experience of transition from student to registered nurse in aprivate hospital graduate program.Australian Journal of AdvancedNursing, 21(1), 14-20.

Kelly, B. (1998). Preserving moral integrity: A follow-up study withnew graduate nurses. Journal of Advanced Nursing, 28(5), 1134-1145.

Kramer, M. (1974). Reality shock: Why nurses leave nursing. St. Louis:

C. V. Mosby.Kramer, M., & Schmalenberg, C. (1978). Bicultural training and ne

graduate role transformation. Wakefield, MA: Contemporary Publishing.

Laschinger, H. K. S., & Leiter, M. P. (2006). The impact of nursin

work environments on patient safety outcomes: The mediating roof burnout/engagement.Journal of Nursing Administration, 36(5259-267.

Lin, L., & Liang, B. A. (2007). Addressing the nursing work environment to promote patient safety.Nursing Forum, 42(1), 20-29.

May, J. H., Bazzoll, G. J., & Gerland, A. M. (2006). Hospitals responses to nurse staffing shortages. Health Affairs, 25(4), W31W323.

Pask, E. J. (2003). Moral agency in nursing: Seeing value in the worand believing that I make a difference.Nursing Ethics, 10(2), 16174.

Purnell, M. J., Horner, D., Gonzalez, J., & Westman, N. (2001). Thnursing shortage: Revisioning the future. Journal of Nursing Aministration, 31(4), 179-181.

Roberts, K., & Farrell, G. (2003). Expectations and perceptions

graduates performance at the start and at the end of their graduayear. Collegian, 10(2), 13-18.

Ross, H., & Clifford, K. (2002). Research as a catalyst for change: Thtransition from student to registered nurse. Journal of ClinicNursing, 11(4), 545-553.

Schoessler, M., & Waldo, M. (2006). The first 18 months in practicA developmental transition model for the newly graduated nursJournal for Nurses in Staff Development, 22(2), 47-52.

Schumacher, K. L., & Meleis, A. I. (1994). Transitions: A central concept in nursing. IMAGE: Journal of Nursing Scholarship, 26(2119-127.

Shields, M. A. (2004). Addressing nurse shortages: What can policmakers learn from the econometric evidence on nurse labor supply? The Economic Journal, 114, F464-F498.

Taylor, C. (2002). Assessing patients needs: Does the same informtion guide expert and novice nurses? International Nursing Rview, 49(1), 11-19.

Tiffany, J. C. (1992). What to expect from your first year of nursinpractice.NSNA Imprint, 39(1), 33-37.


cneARTICLE


11/11

Documents

Duchscher Article