CHAPTER 24 Making the Transition from Student to Professional Nurse

Rutters

Some adopt the attitude that "I'll just do what I have to do to get by," or "I'm just working until I can buy some new furniture." These nurses are called "rutters." They consider nursing just a job.

Assertiveness Skills

Students may be misled into feeling that they are "advanced" in their learning and moving ahead of all the others if they agree to shorten their orientation or if, after only 6 months, they take on the responsibility of caring for patients with special equipment. However, after 6 months, even though novice nurses are becoming more competent and confident, they lack the experience to make instantaneous decisions based on intuition. Unfortunately novice nurses are often employed on the night shift working with nurses with the same or less experience. As newer novice nurses (those who graduated the following semester) are hired, the more experienced novice nurses may even be expected to serve as a preceptor. Faculty should invite recent graduates to speak to classes concerning expectations after employment. Faculty should also inform the students that they will move through many stages during the next year, and they should take full advantage of this learning opportunity.

Compassion fatigue

The gradual decline of compassion over time as a result of caregivers being exposed to events that have traumatized their patients.

Biculturalism

The merging of school values with those of the workplace.

Priority-Setting Skills

asking the following questions when prioritizing: ♦Will patients be jeopardized if this task is not done? ♦Is this task a priority because of time deadlines? ♦What other personnel can perform this task? ♦Do safety concerns make this task a priority? ♦What will be the consequences if this task is postponed? ♦What are the legal issues related to the priority of the task? Many novice nurses need help in organizational skills and saying no is difficult (Gries, 2000). Novice nurses may derive more satisfaction from performing technical skills, such as starting an 506507 intravenous (IV) drip, than from cognitive skills, such as developing a plan of care. Once they are comfortable with basic skills, they move on to critical thinking skills. Gries (2000) stresses that with the loss of the graduate nurse role, novice nurses are propelled into practice, where they focus on what they do not know and are seemingly blind to their accomplishments. For further exploration you can visit an online scenario by Gries of how this can happen to a novice nurse at: http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=800. Gries (2000) also supports the idea of nurses using an organization sheet to facilitate prioritization and completion. How many people make to-do lists? Many make grocery lists, lists of bills to be paid, or lists of important dates. The same should be done for work—tasks are crossed off as they are completed. At the end of the day, consider what time was spent in unproductive ways, what caused interruptions, and what could have been done to save time. Huber (2009) also suggests determining the urgency of the problem, which allows for prioritization.

SPECIAL NEEDS OF NOVICE NURSES The following skills have been identified as needing further refinement in novice nurses. Discussion about each of these areas follows.

♦Interpersonal skills and communication skills (Ricker, 2008; Tingle, 2000) ♦Clinical skills (Gries, 2000; Ricker, 2008) ♦Organizational skills (Tingle, 2000) 504505 ♦Delegation skills (Huber, 2009; Tingle, 2000) ♦Priority-setting skills (Gries, 2000; Huber, 2009; Ricker, 2008) ♦Assertiveness skills

FROM NOVICE TO EXPERT

♦Stage 1: The nurse has few experiences with clinical expectations, and skills are learned by rote; this stage usually occurs while completing the nursing educational requirements. ♦Stage 2: Exemplifies advanced beginners who are able to perform adequately and make some judgment calls based on experience; most novice nurses enter the workforce during this stage. ♦Stage 3: Includes competent nurses who are able to foresee long-range goals and are mastering skills. ♦Stage 4: Includes proficient nurses who view whole situations rather than parts and are able to develop a solution. ♦Stage 5: Includes expert nurses for whom intuition and decision making are instantaneous.

During these five stages of transition from novice to expert, nurses are most likely to experience stress. Stressors common to novice nurses include the following:

♦Unrealistic expectations: novice nurses are expected to care for a standard patient workload as soon as orientation is completed (Chesnutt and Everhart, 2007) ♦Stressful work environments: patient ratios are unrealistic (Bowles and Candela (2005) ♦Powerlessness: novice nurses are not heard when suggesting changes to improve workflow but often are blamed when things go wrong (Mooney, 2007)

Workplace violence

Sexual harassment and abusive acts from patients that can be physical, verbal, and emotional and lead to a hostile work environment. It has been suggested that identifying workplace violence is difficult due to its subjectivity by the recipient.

Role model

A person who serves as an example of what constitutes a competent professional nurse.

Horizontal hostility (also known as lateral hostility)

"A consistent (hidden) pattern of behavior designed to control, diminish, or devalue another peer [or group] that creates a risk to health and/or safety" (Hinchberger, 2009). Bullying, negative insinuations, undermining, and exclusion are examples.

This topic highlights the following objectives: Recognize the influence of positive and negative personal beliefs on professional practice. Identify common stressors that affect the professional practice of nurses. Identify early and late signs of burnout. Determine possible impact of burnout on patients, coworkers, and self. Compare stressors inside and outside the workplace. Differentiate between compassion, fatigue, and burnout. Explain the importance of respecting the beliefs and values of others as a critical component of nursing practice. Recognize signs of common stressors affecting nurses in a given scenario. Evaluate the health and well-being of a given individual based on reactions to common stressors.

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Mentoring

A mutual interactive method of learning in which a knowledgeable nurse inspires and encourages a novice nurse.

Novice nurse

A nurse who is entering the professional workplace for the first time; usually occurs from the point of graduation until competencies required by the profession are achieved.

Preceptor

An experienced professional nurse who serves as a mentor and assists with socialization of the novice nurse.

Honeymoon Phase

During the honeymoon phase everything is just as the new graduate imagined. The new nurse is in orientation with former school friends or other new graduates who often share similarities. Many novice nurses in this phase are heard making the following comments: "Just think, now I'll get paid for making all those beds" and "I'm so glad I chose nursing; I will be a part of changing the future of health care."

Shock (Rejection) Phase

During this phase, the novice nurse may be frightened or react by forming a hard, cold shell around him or herself. Vague feelings of discomfort are experienced, and the inexperienced nurse often wonders whether the other nurses care about the patients. After going home from a shift, the new nurse may experience feelings of rejection and a sense of lack of accomplishment. The novice nurse may reject the new environment and have a preoccupation with the past when he or she was in school. A need to contact former instructors, call schoolmates, or visit the nursing school may occur. Others may reject their school values and adopt the values of the organization. In this way, they may experience less conflict (Kramer, 1974); however, there are drawbacks to this approach as well. During this phase Kramer (1974) suggests that novice nurses must ask themselves two important questions: 1.What must I do to become the kind of nurse I want to be? 2.What must I do so that my nursing contributes to humankind and society? Dealing with the shock phase can be approached in many different ways. Some common approaches for dealing with it are reviewed in the following sections. After that each nurse must decide which method best allows the previous two questions to be answered.

Natives

Many nurses choose to go "native" (Kramer, 1974, p. 161). That is, they decide they cannot fight the experienced nurses or the administration, thus they adopt the ways of least resistance. These nurses may mimic other nurses on the unit and take shortcuts, such as administering medications without knowing their action and side effects and the associated nursing responsibilities.

Transition

Moving from one role, setting, or level of competency in nursing to another; change.

Interpersonal Skills

Novice nurses must listen, ask the appropriate person, and avoid distractions when communicating (Tingle, 2000).

Clinical Skills

Novice nurses often lack trust in experienced nurses to help them problem solve clinical situations (Pine and Tart, 2007). Practice increases the effectiveness, efficiency, and correctness of performing skills. However, until the nurse has experience, there are actions the novice nurse can take. For example, it is wise to be familiar with the procedure manual on the unit. Also during the orientation phase, the novice nurse should ask to observe or assist an experienced nurse with procedures for which there is a lower comfort level or a lesser degree of experience. It is important to remember that no skill is "basic," and step-by-step instructions, such as those found in procedure manuals, are helpful (Gries, 2000). Remember that everyone had to learn these skills. No one was born with a Foley catheter in one hand and the set of directions engraved in memory.

Delegation Skills

Novice nurses should familiarize themselves with policies concerning which tasks can be performed by which category or level of health care provider. The question "Who can perform this task other than myself?" should be considered. Because of the broad span of responsibility for most nursing jobs, it is impossible for one person to complete all the work alone (Huber, 2009). Delegation relies on trust and leadership skills, both of which may be deficient in the novice nurse. Chapter 19 presents a comprehensive overview of delegation. There are also times when the novice nurse should decline to accept a delegated responsibility because he or she may not be competent to perform the task even though it is within his or her scope of practice. Remember that patient safety is always the priority. Show your willingness to learn and ask someone to demonstrate the task. Tingle (2000, p. 3) suggests simply stating, "I haven't done this; who can talk me through it?" or "I don't know how to do that, but I am willing to help with it."

Reality shock

Occurs when a person prepares for a profession, enters the profession, and then finds that he or she is not prepared.

Runaways

Others choose to "run away." They find the real world too difficult. These new nurses may choose another occupation or return to graduate school to prepare for a career in nursing education to teach others their "values in nursing."

Organizational Skills

The novice nurse may lack organizational skills. This lack of proficiency may be exaggerated by feelings of being "overwhelmed" by the new environment. Typically, student nurses are responsible for a limited number of patients, and although they must answer for their care, they typically are not responsible for as many patients as they will be assigned as new nurses. Someone is usually with students to offer suggestions on how to organize their time. The instructor might question: "Now what do you plan to do, and what supplies will you need to accomplish the task?" New nurses might consider asking these same questions. If unsure the procedure book lists not only the steps to follow but also the supplies that will be needed. List specific time-limited tasks. Avoid scheduling time so tightly that a slight delay causes chaos. Planning and prioritization skills were seen as an area of concern of newly graduated nurses (Lofmark, Smide, and Wikblad, 2006). Chapter 25 offers valuable tips on getting organized, setting priorities, and managing time.

Socialization

The nurturing, acceptance, and integration of a person into the profession of nursing; the identification of a person with the profession of nursing.

Resolution Phase

The resolution phase is the result of the shock phase combined with the novice nurse's ability to adjust to the new environment. If the nurse is able to positively work through the rejection phase, he or she grows more fully as a person and a professional nurse during the resolution phase. Work expectations are more easily met, and the nurse will have developed the ability to elicit change.

Recovery Phase

The return of humor usually is the first sign of the recovery phase. The novice nurse begins to understand the new culture to a certain degree. There is less tension and anxiety, and healing begins. The nurse in this phase may comment, "I'll hang that blood, and I'll bet I can infuse it before 8 hours this time."

Change Agents

These are the nurses who care enough to work within the system to elicit change. They frequently visit the nurse manager or head nurse to suggest change or a better way. They keep the welfare of the patient at the forefront. Unfortunately, Kramer refers to these nurses as "bicultural troublemakers" (1974, pp. 91-93).

Burned Out

These nurses bottle up conflict until they become burned out. Kramer (1974) describes the appearance of these nurses as having the look of being chronically constipated. In this situation, patients may feel compelled to nurse their nurse. Inexperienced nurses may become burned out because they assume too many responsibilities in a short period of time (Domrose, 2000). Some common symptoms of burnout include extreme fatigue, headaches, difficulty sleeping, mood swings, anxiety, poor work quality, depression, and anger (Larsen, 2000). The more intelligent, hard-working nurses are the most prone for burnout, but if you exhibit these symptoms; remember that they can be reduced.

New Nurse on the Block

These nurses change jobs frequently. They go from the hospital setting to community health to the physician's office. They are always new in their setting and therefore adopt the attitude of "teach me what you want; I'm new here."

Loners

These nurses create their own reality. They adopt the attitude of "just do the job and keep quiet." These nurses may prefer night shifts, during which they often are "left alone."

VIOLENCE AT WORK: Types of Workplace Violence

Type 1 These violent acts are not committed by employees; rather criminals are the perpetrators of the crime on entering the health care agency/organization. Type 2 Patients become perpetrators of violent acts. Type 3 Prior or disgruntled employees commit violence against current employees and/or management. Type 4 Individuals who have a relationship with a current employee commit a violent act in the health care environment. Type 5 Violence that occurs between workers; known as horizontal violence.