Faculty's Role in Assisting New Graduate Nurses' Adjustment to Practice

Introduction

The gap between the role of the nursing student and that of the practicing registered nurse is well known. Kramer (1974) used the term “reality shock” (p. 9) to explain the anxiety, doubt, and confusion nurses experience as they advance from the role of nursing student to professional registered nurse. Reality shock, also called role transition, leads as many as 30% of new nurses to leave the profession or change jobs within their first year of employment (Duchscher, 2009). While studies show how the health-care industry addresses the problem of reality shock (Bowles & Candela, 2005; Duteau, 2012; Dyess & Sherman, 2009) and the successful preparation of students' entry into nursing in terms of student achievement (Benner, Sutphen, Leonard, & Day, 2010; Billings & Halstead, 2012), neither approach thoroughly explores the role of nursing faculty from the perspective of the student preparing for the professional role (Benner et al., 2010).

Institutions of higher education have been called upon to better equip graduates with the tools necessary to compete in the workforce (Cornish, 2004). Nursing educators recognize they have an ethical and professional obligation to prepare students to enter practice ready to master the skills needed to ensure safe, high-quality patient care (Benner et al., 2010). Nursing faculty recognize the need to provide an educational experience and positive learning environment for all students, resulting in educators continually introducing multiple teaching, learning, and assessment techniques to support students' learning successes (Billings & Halstead, 2012). Teaching technique evaluations determine whether a methodology improves cognitive and psychomotor learning (Benner, 2001; Billings & Halstead, 2012), but more information is needed to determine what effect multiple teaching methodologies and faculty behaviors have on promoting new nurses' clinical competence and confidence.

This research study examines the impact of nursing faculty behaviors on role transition from the perspective of newly graduated registered professional nurses. For purposes of this study, newly graduated nurses are defined as having less than 3 years of experience. Understanding which nursing faculty behaviors promote a smooth transition from the role of student to that of professional practice may inform nursing faculty of the impact of their behavior on new graduate nurses and encourage more new nurses to remain in the profession.

Background/Literature

The ability of the new graduate nurse to adapt to the role of professional registered nurse has been examined repeatedly since Kramer (1974) introduced the concept. Early studies intent on improving orientation programs examined how role transition affects attrition rates (Schempp & Rompre, 1986), with studies on role transition changing as needs of the health-care industry evolved. For example, Myrick (1988) studied the implementation of preceptorships, and others examined preparedness of new graduate nurses by scrutinizing the educational process and developing educational standards (American Association of Colleges of Nurses, n.d.; Benner et al., 2010; National League for Nursing, n.d.).

Three theoretical frameworks support the assumptions of the researcher. First, the framework of Kramer's (1974) reality shock is used to outline the significance of the problem. Benner's (2001) novice-to-expert theory provides a foundation for understanding the cause and effect of role transition and the new graduate nurse. The theoretical framework for this study is further expanded through Roy and Andrews's (1991) theory of adaptation, supporting the importance and purpose of the study.

Kramer (1974) asserted that reality shock occurs in nursing because the level of commitment is viewed as permanent, and literature continues to report on reality shock for all new graduate nurses (Martin & Wilson, 2011). New graduates must develop organizational skills to function effectively, productively, and indefinitely (Kramer, 1974). Student-based cognitive and psychomotor skills are tested as new nurses strive to acquire nursing skills and adapt to organizational expectations. The complex process of transition involves more than knowledge, technical skills, and abilities.

Reality shock shares basic concepts with culture shock. Culture shock (Oberg, 1960) is the phenomenon experienced by Western society travelers who venture to Third World countries and vice versa. Differences of language, customs, and social norms burden newcomers, leaving them feeling alienated. Successful acclimation always results in the person accepting and enjoying the attributes of the new culture (Oberg, 1960).

Kramer's (1974) outline of reality shock includes the phases of honeymoon, shock, recovery, and finality. New graduates in the honeymoon phase are excited about embarking on a new career. They enter the workplace with euphoria and an idealistic understanding of their professional role. The euphoria is short-lived, and the honeymoon phase ends abruptly; new graduates no longer recognize the familiar signals of school. Shock and rejection set in, and new graduates become anxious, angry, and confused (Kramer, 1974). Equivalent with the negotiation or disintegration stage of culture shock, the shock phase results from inconsistencies between what was previously perceived as normal and what is now being presented as normal in the new surroundings (Kramer, 1974; Oberg, 1960). During the shock phase, the most extreme responses are seen, resulting in medical errors, multiple job changes, or abandoning the profession of nursing (Duchscher, 2009; Morrow, 2009; National Council of State Boards of Nursing, n.d.). New graduates equipped with the tools to successfully navigate through the shock phase progress to the recovery and final phase, evolving from an advanced beginner to a competent practitioner (Benner, 2001).

Benner's (2001) novice-to-expert theory, first published in 1982, embodies the concept of nurses developing professional expertise over time. This theory describes performance characteristics and learning needs of the professional nurse during various stages of clinical practice. A person acquires or perfects skills through trial and error, or by seeking professional instruction (Dreyfus & Dreyfus, 2000). Skill acquisition is a process consisting of five developmental stages: novice, competence, proficiency, expertise, and mastery (Dreyfus & Dreyfus, 2000). The novice has little or no experience (Benner, 2001). Generally, novices are nursing students. Nursing students are inflexible; their behavior is limited to theory and rules. The new graduate is considered an advanced beginner (Benner, 2001). Clinical experience learned in school is the knowledge base that guides care (Martin & Wilson, 2011), but the advanced beginner lacks the skills to effectively identify patient needs and prioritize care (Benner, 2001). The competent nurse has developed the ability to plan and organize efficiently; his or her actions are viewed in the context of developing long-term goals, both patient-centered and professional. As the nurse remains in practice, proficiency and expertise are achieved. The proficient nurse can visualize situations as a whole and easily recognize deviations from the norm (Benner, 2001). The expert requires no expenditure of energy to understand a situation; decisions are made quickly, without the need for considering rules or alternative solutions (Benner, 2001; Dreyfus & Dreyfus, 2000).

Skills acquisition occurs secondary to experience. Experience is not defined by time; it is a process of reflection and reconstruction of preconceived assumptions amid real-life situations (Benner, 2001). A nurse progresses from novice to expert as mastery is achieved in each practice domain. In other words, a nurse in the early stages of skills acquisition relies on strict adherence to rules; he or she cannot transform the characteristics of the domains of practice and apply them (Gentile, 2012). The domains of nursing practice are the helping role, the teaching-coaching function, the diagnostic and patient-monitoring function, effective management of rapidly changing situations, administering and monitoring therapeutic interventions and regimens, monitoring and ensuring the quality of health-care practices, and organizational and work-role competencies. The expert nurse uses reflection to synthesize multiple experiences, allowing for a nonlinear, holistic response (Benner, 2001; Gentile, 2012). To achieve expertise in practice, the nurse must master each earlier stage (Benner, 1991; Dreyfus & Dreyfus, 2000). Progression through the levels of expertise has implications for education and professional development.

Transforming from novice to expert allows the new graduate nurse to be viewed as an adaptive system (Roy, 1988). As an adaptive system, the new nurse experiences multiple stimuli, adjusts behavior accordingly, and produces responses that effect changes in the environment (Roy & Andrews, 1991). Stimuli-triggered behavior is either adaptive or ineffective. An ineffective response hinders the nurse from growing in a situation. A single ineffective response usually is not problematic, but repeated and ongoing ineffective responses prevent adaptation (Roy & Andrews, 1991). Failure to adapt is exemplified by the new graduate who has difficulty progressing through reality shock and cannot progress from advanced beginner to competent practitioner. High attrition rates and increasing costs of new graduate orientation are consistent with ineffective responses in nursing (Pinchera, 2012). Many studies suggest unpreparedness contributes to the high rate of care errors by new nurse graduates (Benner et al., 2010; Culleiton, 2010; Saintsing, Gibson, & Pennington, 2011). Ineffective responses such as errors foster feelings of inadequacy and frustration, undermining professional relationships and successful professional development (Pinchera, 2012). Understanding the obstacles new graduate nurses encounter may allow for the creation of stimuli promoting adaptive responses, thereby avoiding disequilibrium of the personal self (Roy & Andrews, 1991) and support an easier transition through the phases of reality shock.

Despite ongoing improvements in nursing education, 21st-century nurses enter the complex health-care environment without the skills and knowledge needed to practice (Benner et al., 2010). An estimated 25% of new graduate nurses lack critical reasoning and problem-solving skills, leaving them unable to provide safe patient care (Fero, Witsberger, Wesmiller, Zullo, & Hoffman, 2009; Saintsing et al., 2011). These nurses lack the capacity to maintain and enhance the knowledge base for continued safe, high-quality patient care (Benner et al., 2010). Education, experience, and personal factors such as parental relationships, general career expectations, and economics all play a role in the new graduate's ability to acclimate to professional practice (Farner & Brown, 2008). Feelings of helplessness and anxiety have an impact on the new graduate's progression into practice and undermine professional development (Pinchera, 2012). Continuing research may improve educational methods to ensure new graduate nurses enter professional practice prepared to meet health-care industry demands (Benner, 2001).

Various orientation programs and residency programs have been proven to benefit the socialization process (Berkow, Virkstis, Stewart, & Conway, 2008). Lampe, Stratton, and Welsh (2011) noted orientation programs that meet new graduates' specific needs are more likely to empower, but orientation program effectiveness depends on new graduates' knowledge base upon entering the program (Benner et al., 2010). Reducing reality shock and improving empowerment are linked to improved retention and professional satisfaction.

Industry educators and nursing faculty recognize the need to reevaluate the nursing curriculum and minimize the turbulent transition from student nurse to professional registered nurse (Benner et al., 2010; Greene, 2010). Members of the current health-care industry expect nursing faculty to educate students who are ready for the challenges of professional practice (Roberts, Lockhart, & Sportsman, 2009).

Method

Research Design

Grounded theory was used to define the basic social process behind reality shock and develop a beginning theory grounded in the data (Glaser & Strauss, 1967) to answer the research question. Grounded theory methodological rigor provided structure for development of the beginning theory, allowing the theory to remain grounded in data and truthful to the study purpose.

In grounded theory, sample size is guided by the data. Data were collected until a complete understanding of the topic was achieved (Charmaz, 2006). After obtaining Internal Review Board approval through Capella University, an Ohio Board of Nursing listserv was used to contact potential participants who satisfied the inclusion and exclusion criteria (Table 1). Potential participants were mailed a request for further contact form containing the inclusion criteria. Of the 700 requests for further contact sent, 24 were returned.

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Table 1.

Inclusion and Exclusion Criteria.

Inclusion criteria	Exclusion criteria
Graduated within the past 3 years	Graduated more than 3 years prior
Passed NCLEX-RN on first attempt	Passed NCLEX-RN after multiple attempts
Consistent employment at same institution for a minimum of the past year	Employed by multiple institutions within the past year
Nursing is the first career	Previous career(s) held
Never worked in a job requiring patient care	Previously engaged in patient care
Did not participate in a formal residency program	Participation in a formal residency program

Note. NCLEX-RN = National Council Licensure Examination-Registered Nurse.

Potential participants were contacted using the information provided by the Ohio State Board of Nursing. Twenty participants were successfully recruited for interviews. At the start of the interviews, the study was explained, and verbal consent was obtained. Participants were made aware that the interviews would be recorded and that the recordings would be kept in a locked file cabinet. All participants were assigned a study number. The transcriptions of the interviews contained only the study number. Only the investigator has access to the recordings and study numbers. Data saturation was achieved after 13 participants were interviewed.

Data coding provided the framework for generating theory quintessential to the reality it embodies (Strauss & Corbin, 1990). Coding to generate theory followed a process of constant comparison (Glaser & Strauss, 1967) using open coding, followed by axial coding, followed by selective coding. Open coding was performed as each interview tape was transcribed, exposing initial concepts and meanings that guided further data collection (Corbin & Strauss, 2008). As data emerged, concepts were identified, analyzed, compared, and categorized.

Focused or axial coding was conducted next. Axial coding asks “when, where, why, who, how, and with what consequences” (Strauss & Corbin, 1998, p. 125). The coding process concluded with selective coding. Selecting coding involves creating a case study or story derived from the data (Strauss & Corbin, 1998). Creating a case study places the collected data into context, providing the framework for the beginning theory development.

Thirteen participants provided individual points of view regarding nursing faculty behaviors. Telephone interviews were analyzed and coded using grounded theory. Constant comparison of data using multiple methods of coding supported an unremitting relationship between data collection and analysis, thereby sustaining validity of the grounded theory methodology (Bryant, 2009; Glaser, 2003; Glaser & Strauss, 1967). As data representing each participant's point of view were analyzed using open coding, axial coding, and selective coding, common concepts, themes, and categories became apparent. The final categories that emerged are caring, rigor, experience, knowledge, and professionalism.

Data/Results/Findings

Participants correlated their memories of student experiences with the ability to handle obstacles as they launched their professional career. The central theme was caring, identified through several stories. Examples included how appreciative participants were of nursing faculty who took extra time to review or explain content. Participant 5 remarked, “I always went to one professor when I didn't understand something. …[She taught] me how to look up what I didn't know… .Being able to gather information quickly helped me in the beginning.” Participants related nursing faculty's ability to demonstrate caring with the ability to learn, apply knowledge, and reflect fairly on their own performance.

Each participant mentioned program rigor, correlating adherence to a rigorous program with his or her ability to manage stressful situations at work. One participant said, “[M]y manager complemented … my professional attitude … [M]y professors … enforc[ed] … policies … [C]oworkers … treat me with [more] professionalism … ”

The most common sentiment referred to the ability to adapt to social nuances. Several participants referenced older, more experienced nurses as “eating their young” (Participants 3, 5, 15, and 16). Participants stated that because they were comfortable adhering to policies and acting professionally, they were not mentioned in discussions about the problems new nurses presented. Being excluded from such conversations gave these newly graduated nurses confidence that made the transition from student to professional registered nurse more pleasurable.

Experience and knowledge was a substantive category. Participants repeatedly expressed admiration for the vast knowledge nursing faculty presented, as well as nursing faculty's ability to share knowledge and experience with students. Participants correlated nursing faculty knowledge with a desire to gain knowledge for themselves. All the participants noted having a strong knowledge base eased their transition process. “Professor M … seemed to know everything … Every time I … don't know … the diagnosis … I [use her process] to quickly learn … the problems … that weren't part of [patients'] diagnoses” (Participant 3).

The final substantive category identified is professionalism. Participants spoke about poor nursing faculty behaviors and attitudes as being unprofessional. Nursing faculty identified as favorable were referred to as having those qualities that students expected registered professional nurses to have. “I think one of the best things that any of the professors did was treat us all like professionals from the start” (Participant 5). During member checking, participants were asked if nursing faculty attitudes affected their ability to adjust to the professional role. Participants noted how they aligned themselves with the actions of nursing faculty they believed represented professionalism.

Discussion

The purpose of this grounded theory research was to develop a theory that allowed for the understanding of nursing faculty behaviors that influenced new graduate nurses' ability to have a successful role transition from student to professional registered nurse. Once understood, the Faculty Attributes for Confidence, Equilibrium, and Success (FACES) theory was developed. The intention of the FACES theory is to provide guidance to nursing faculty regarding which attributes and behaviors help the new graduate nurse decrease their anxiety and stress during their transition from student to registered professional nurse. Another intention is that when nursing faculty reflect upon individual actions and attributes while considering the components of the FACES theory, nursing education will be enhanced. Students should leave the academic setting prepared to meet the demands of the health-care industry and successfully pass the NCLEX.

Categories formed indicated nursing faculty's caring attitude served as a guide to how the new graduate should act when working in a health-care institution. Participants remarked on their confidence when they encountered unknown situations as long as they remained calm and caring. They equated caring with nursing faculty taking time to view each student as an individual. Participants correlated the time nursing faculty took to care with a more inspiring learning environment. Nursing faculty's caring approach to teaching also set an example for the new graduate nurse to follow in rendering patient care. Students were comfortable seeking help from nursing faculty who depicted a caring attitude. When content was difficult to understand, students sought assistance from nursing faculty they believed cared. These faculty simplified the difficult content, thus increasing the students' knowledge base. The process of increasing students' knowledge base through content simplification could increase new graduates' power of inquiry. An increased power of inquiry and knowledge base might equate with an increase in learning throughout a nurse's professional career (Benner et al., 2010).

Study participants discussed professionalism and some nursing faculty's unprofessionalism. Nursing faculty who laughed and acted facetiously outside the classroom but maintained a professional tone in the classroom or clinical setting provided positive examples on how to remain professional and interact with colleagues in a relaxed manner. Participants admitted to liking a nursing faculty–student bond of friendship during the educational experience and that the actions of nursing faculty who remained professional and caring in all situations served as a guide when adapting to the social structure of the health-care industry. Nursing faculty's responses in difficult or challenging situations provided a basis for decreasing anxiety and stress when the new graduate encountered unexpected or unknown situations.

Participants were inspired by the vast knowledge portrayed by nursing faculty. Disseminating knowledge using teaching methods such as narrative andragogy and real-life case studies motivated students to study harder, thereby developing a stronger knowledge base. The use of multiple technological venues in the classroom and clinical setting bolstered new graduates' confidence in their ability to find and learn new information independently. Participants reported nurses with many years of experience complemented the new graduates and express pleasure in working with them. When these senior nurses expressed satisfaction with the new graduates' actions, confidence was boosted, decreasing stress and anxiety.

Experience was referred to in the context of clinical nursing experience, as well as with using multiple teaching, learning, and assessment techniques in the classroom and clinical setting. Participants noted the use of high-stakes simulation with critical cases derived from actual nursing faculty experiences taught students not only content but also how to use critical thinking and reasoning skills in high-pressure situations. The new graduates reported believing most of the situations they encountered when adjusting from the role of student to that of professional registered nurse were high-pressure circumstances. Having experienced functioning in high-stakes simulations reduced the new nurses' anxiety and increased their ability to think critically instead of being frightened and flustered when caring for patients. Participants considered the capacity to critically think in challenging situations as a key component to a successful transition.

Participants expressed dislike for nursing faculty who were strict and always adhered to policies without exception, but, once these former students assumed the role of professional registered nurse in the workplace, they appreciated the nursing faculty who adhered to rigor in policies, assignments, appearance, and punctuality. Participants explained that being expected to adhere to rigorous standards in school made it easy to adapt to workplace policies. The equilibrium of expectations enforced through rigor in school prepared new nurses to meet workplace expectations. Participants reported colleagues who found work policies overwhelming had educational experiences in which rules were not routinely enforced. Many found having policies enforced on a case-by-case basis increased new graduates' stress levels. Participants expressed that their colleagues who reported very high stress levels no longer worked with study participants in the hospital.

Statements centered on nursing faculty having a caring attitude, adhering to rigor, treating all equally and fairly, possessing vast knowledge, incorporating personal experiences into teaching, and always portraying a sense of professionalism in actions led to the development of the FACES theory (Figure 1). Participants indicated all five attributes are equally important. The five points of the star represent the individuality of each attribute. Arrows connecting the attributes indicate the need for all attributes to be present in the educational arena. Nursing faculty who demonstrate all five attributes in their behaviors decrease new graduate nurses' stress and anxiety in the transition from student to professional registered nurse. OPEN IN VIEWER

Conclusions

Reforming nursing education so that students graduate better able to meet the demands of the health-care industry is paramount. Nursing leaders have focused on revising content now and developing standards for nursing programs later (National League for Nursing, n.d.). The goal of this research was to develop a beginning theory identifying nursing faculty behaviors that influence nursing students, making the transition from student to professional registered nurse less stressful. Interviews with new nurses make it clear that transfer of information is not enough. Nursing faculty need to lead by example.

Attributes that allow nursing faculty to lead by example led to development of the FACES theory. These characteristics, derived from strict adherence to the process of constant comparison, open coding, axial coding, and selective coding, are caring, professionalism, rigor, knowledge, and experience. Developing these physiognomies requires nursing faculty to become critically reflective of their teaching (Brookfield, 1995). It is reasonable to conclude that it is imperative to new nurses' successful transition that nurse educators fully develop a caring attitude, maintain professional behavior at all times, be fair and rigorous regarding policies and assignments, and maintain current knowledge and experience in the health-care industry, as well as in the practice of adult education. Each characteristic represents an individual component of the holistic educational process. All five attributes must be present for students to perceive nursing faculty are mentors, as well as educators.

The practice of nursing education today emphasizes knowledge acquisition and knowing without stressing learning in the context of clinical inquiry (Benner et al., 2010). The FACES theory provides guidance to nursing faculty on what is necessary to change how future nurses are educated. An education placing high value on nursing faculty leading by example decreases the stress and anxiety of reality shock, facilitating new graduates' use of critical thinking and reasoning to provide safe patient care. Because successful orientation depends on new graduates possessing the knowledge and tools of an advanced beginner, possibly even nearing a competent practitioner, enhancing nursing education through implementation of the FACES theory may have a positive impact on patient outcomes.

Study limitations include the researcher's previously held assumptions, the participant pool, and use of grounded theory. It is assumed that information obtained from the participants' pool in Ohio is transferable to all new graduate nurses throughout the United States. Strict adherence to the rigor of grounded theory data collection and coding is recognized as reducing researcher bias and the methodology of grounded theory itself. Supplementary research is needed to further validate the theory. A quantitative inquiry relating a decrease in medical errors to a less stressful role transition would benefit nursing faculty, as well industry educators, to close the gap between education and professional practice. Educators who maintain caring, professional, and rigorous behavior, as well as current knowledge and experience, and portray these characteristics to students increase new graduates' ability to enter practice prepared and confident to manage the social structure of the health-care industry and achieve positive patient outcomes.

Specific nursing faculty behaviors that increased new graduates' self-efficacy and decreased symptoms of reality shock were identified, although measurable criteria such as the correlation between decreased reality shock and reduction in medical errors were not identified. This study captured beliefs related to the phenomenon of reality shock for new nurses in the north central and northeastern United States. Replicating this research in other areas of the United States and in other countries would improve credibility the FACES theory. Replicating this research by including second degree nurses, second career nurses, and older nurses entering their first career could also increase the credibility of these research findings.

Increased knowledge and skill levels of new graduates exposed to these attributes have yet to be correlated. Can nursing faculty's behaviors be linked to first-time pass rates on NCLEX? Could a reduction in medical errors be identified when new graduate nurses are better prepared for reality shock? It was unintentional that all of the new graduates who participated in this study were baccalaureate prepared. There is a need to study nursing faculty behaviors of new graduates who enter professional practice with an associate's degree. Several of the attributes identified equate to being a critically reflective educator (Brookfield, 1995). Studying the impact of implementing a protocol for nursing faculty to follow that encourages critical reflection of education practices may enhance student outcomes, thereby improving nursing education.