reality shock
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Reality ShockThe Experience of Transition from Student Nurse to Registered Nurse
MDJ 4402 Nursing ManagementFa
culty
of M
ed
icine a
nd
Health
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Un
iversiti M
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Sara
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r of N
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201
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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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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)
What is Reality Shock?
How Reality Shock Emerges
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How Reality Shock Emerges
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
Strategies to Reduce Reality Shock
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Strategies to Reduce Reality Shock
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
Source: Broad, Walker, Boden & Barnes (2011)
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
Source: Broad, Walker, Boden & Barnes (2011)
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?
Nurse Residency Program
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.
Source: Thrall, 2007
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.
Source: Thrall, 2007
Nurse Residency Program
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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