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Challenging the shock of reality through digital storytelling
Nurse Education in Practice 11 (2011) 159e164
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Challenging the shock of reality through digital storytelling Gemma Stacey a,1, Pip Hardy b, * a b
Division of Nursing, University of Nottingham, London Road Community Hospital, London Road, Derby DE1 2QY, United Kingdom Patient Voices Programme, Pilgrim Projects Limited, 91 Waterbeach Road, Landbeach, Cambridgeshire CB25 9FA, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 9 August 2010
The transition from student to qualified nurse is widely acknowledged to entail a difficult period of adjustment, involving significant personal and professional challenges. Kramer [1974. Reality Shock e Why Nurses Leave Nursing. Mosby, St. Louis] originally described this as a “reality shock” due to the dissonance experienced between the expectations of the newly qualified nurse and the actuality of clinical practice. This experience continues to be echoed throughout the literature exploring factors influencing the quality of compassionate care, post-qualification support strategies, and attrition rates. Despite this, the phenomenon of a reality shock appears to have been accepted as an inevitable aspect of professional socialisation. This paper aims to report on an educational development which attempted to challenge these negative experiences and outcomes. The Division of Nursing at the University of Nottingham worked alongside the Patient Voices Programme (www.patientvoices.org.uk) to create reflective digital stories of newly qualified nurses. In their own words and using personal photos, the newly qualified nurses relate stories about an event that they have found particularly challenging during the transition from student to nurse. The stories were intended to provide opportunities for future students to learn and educationalists to reconsider the curriculum to facilitate preparation for the world of clinical practice. A learning environment was developed and piloted that utilises the digital stories to encourage student nurses to reflect upon the challenges of this transition by engaging with the storytellers, empathising with their experience and considering ways they might respond in similar situations. Evaluation of this educational forum suggests that the digital stories offer the audience a unique opportunity to walk in the shoes of the storyteller. As a consequence, an altered story might be told through encouraging newly qualified nurses to develop their core strengths and, in doing so, maintain their capacity to care. Ó 2010 Elsevier Ltd. All rights reserved.
Keywords: Digital stories Professional socialisation Reality shock Reflection Patient Voices
1. Literature review The evidence base that reports on the transition from student to newly qualified nurse acknowledges that it often entails a difficult period of adjustment involving many significant personal and professional challenges. Kramer (1974) originally described this phenomenon as a ‘reality shock’ and defined it as ‘the reactions of new workers when they find themselves in a work situation for which they have spent several years preparing and for which they thought they were going to be prepared, and then suddenly find they are not’. This experience continues to be echoed throughout the recent literature exploring the lack of post-qualification support strategies, low job satisfaction and high attrition rates (Robinson * Corresponding author. Tel.: þ44 7721 751784. E-mail addresses: [email protected] (G. Stacey), pip@pilgrimprojects. co.uk (P. Hardy). 1 Tel.: þ44 1332 347141x2558. 1471-5953/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2010.08.003
et al., 2005; Forsyth and McKenzie, 2006). The consequences are significant as the coping strategies that newly qualified nurses employ to rectify this dissonance are shown to have negative effects on quality of care and maintenance of person-centred values (Mackintosh, 2006). Despite this issue being reported first in 1974, the phenomenon of a ‘reality shock’ appears to remain and seems to have been accepted by education and practice as an inevitable aspect of professional socialisation. The process of professional socialisation, often described in the literature, suggests that the nursing profession exists as a powerful structural reality and that newcomers are little more than passive recipients of knowledge who are being moulded into what the profession defines as ‘good’ professionals. Clouder (2003) explains this apparent conformity in two ways: ‘learning to play the game’ and ‘presentation of self ’. Playing the game involves becoming aware of rules, both written and unwritten, and learning to comply with the systems in place. This process requires recognition of the power differentials inherent in being a newcomer seeking to join
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the profession. Clouder (2003) recognised that students perceive a need to present or act in accordance with expectations throughout the identification process. Clouder (2003) draws upon the work of Goffman (1959) who emphasises how people negotiate daily life and make conscious decisions about how they present themselves in the public arena to fit in with social practices identified by the profession. It is, therefore, vital that newcomers begin to position themselves in relation to expectations. Contemporary research into the professional socialisation of nurses has also recognised the relevance of the values that are associated with a profession. Fagermoen (1997) emphasises the importance that values and beliefs play in shaping the professional identity and consequent socialisation of a nurse, saying a nurse’s identity is defined by these values and ‘represent her philosophy of nursing,’ (p. 436). Similarly, Mackintosh (2006) identified a juxtaposition between different and opposing sets of values within nursing. Despite the assumption that a personal relationship and emotional support are essential elements of the nurse’s role, Mackintosh maintains that this emotional caring ethos is discouraged to enable nurses to prioritise-task-based care needs. The result is personal disillusionment amongst nursing students and the development of cynical attitudes about the caring aspect of their role. Maben et al. (2006) attempted to consider the specific aspects of nursing practice which may be contributing to this kind of emotional and moral distress. This research indicates that although nurses emerge from their educational programme with a strong set of professional values, a number of organisational factors sabotage their implementation. The factors at play include a lack of support, poor nursing role models, time pressure, role constraints, staff shortages and work overload. Kelly (1998) supports these themes and identified the importance of ‘preserving moral integrity’ as the basic psychosocial process when newly qualified nurses adapt to the ‘real world’ of work. She suggests moral distress results when newly qualified nurses believe they are not living up to their moral convictions and highlighted the prevalence of self-criticism and self-blame in this process. Here, newly qualified nurses become intensely aware of the discrepancy between their perceptions of good nursing and what they observe in practice. They cope with this by redefining their perceptions of their role. This process allows the student to rationalise the accepted poor nursing practices rather than questioning or confronting them. This view is supported by Mackintosh (2006) who maintains that nursing students are coping with this moral distress and identified that the minority of students recognised the practice of poor role models and rejected its influence. However, others rationalised these practices as a consequence of the working organisation or the type of service users they were working with. Some felt that the ability to ‘switch off’ from the emotional aspects of nursing practice was essential to cope with the emotional demands of the nursing role and therefore a skill which they whished to acquire. A body of evidence presents a view of how established staff may influence the experience of newly qualified nurses entering the profession. Evidence suggests poor role models who devalue care have been shown to cause personal disillusionment and have a negative influence on the maintenance of humanistic values (Greenwood, 1993; Mackintosh, 2006). Adding to this concern, several studies recognise the danger of newly qualified nurses becoming desensitised to poor nursing practice habits and adopting them as their own (Greenwood, 1993; Holland, 1999). It has been suggested that this can lead to a tendency amongst students to shift their self-identity in order to justify the loss of ideals and become proficient in their new role. Newly qualified nurses who initially challenge issues of concern are quickly discouraged if not supported by senior colleagues and so the disposition to resist may coexist with
a desire to appear to conform. It is suggested that this process will have a negative effect on newly qualified nurses, who may lose their skills as ‘knowledgeable doers’ and ‘confident analytical thinkers’ as they become socialised into a culture where routine and task-based work approaches are more highly valued (Jowett et al., 1991). Even more seriously, Brookfield (1993) referred to the term ‘cultural suicide’ in suggesting that practitioners who choose to take ‘a critical stance towards conventional assumptions and accepted procedures face the prospect of finding themselves excluded from the culture that has defined and sustained them up to that point’ (p. 200). This interpersonal conflict among nurses, termed ‘horizontal violence’, was explored by Mckenna (2003) who identified this as a significant issue confronting new graduates within the nursing profession. This is the phenomenon underpinning nurses’ references to their profession ‘eating their young’ (Longo, 2007, p. 177) referring to an act of subtle or overt aggression perpetrated by one colleague toward another colleague (Mckenna, 2003; Randle, 2003; Longo, 2007). The research evidence offers a number of explanations for the continued experience of “reality shock” and the reasons why current models of preparation for practice are not addressing the complexity of the issues. Despite this vast evidence base, it appears that there have only been limited attempts to prepare students for this difficult transition process during their pre-registration training. This paper will report on an educational development that has attempted to challenge this negative experience. The development project encompassed 3 distinct phases. Phase 1 involved the development of 8 digital stories with newly qualified nurses followed by a focus group discussion on their experiences of the story making process. Phases 2 focused on designing an educational forum for the use of the digital stories through the facilitation of a workshop with individuals who had expertise in the area. The final phase involved the implementation and evaluation of the education forum with student nurses. 2. Digital storytelling and Patient Voices We learn, according to Dewey (1938) and others, not from our experience, but by reflecting on experience. Reflection is a key skill for professionals, offering them ‘a structured means of studying processes and challenges and making connections between their personal and professional lives’ (Hardy, 2007). However, as Schön (1987) reminds us, ‘Stories are products of reflection, but we do not usually hold onto them long enough to make them objects of reflection in their own right.’ The first stage of our project, therefore, offered eight newly qualified nurses an opportunity to reflect on recent experiences through the creation of their digital stories during a three-day workshop facilitated by Pilgrim Projects’ Patient Voices Programme. The Patient Voices Programme is a social enterprise that aims to facilitate the telling and sharing of the unwritten and unspoken stories of ordinary people’s experiences of healthcare in the hope of influencing clinicians, managers and decision-makers to commission, design and deliver more compassionate and humane healthcare (Patient Voices Website) (www.patientvoices.org.uk). All of the stories in the Programme are created in small, carefully facilitated workshops. The Patient Voices methodology has been refined over the past seven years, based on the workshop process designed and developed by the Centre for Digital Storytelling (www. storycenter.org) over nearly twenty years. Using techniques drawn from creative writing, community theatre, narrative and art therapy, storytellers are gently guided through the stages of: considering the elements of a good story; sharing their initial story idea and developing it in the story circle; editing, refining and distilling the story to reveal its essence and
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discover its meaning; recording their story; selecting appropriate photos; learning the basics of image and video editing; and, finally, becoming directors of their own movies. Storytellers have control over their story at all times, and participate fully in every stage of the process that results in the finished short movie, so that the endof-workshop premier is a true celebration of a significant accomplishment, shared by storytellers and facilitators alike. A careful, two-stage consent and release process ensures that storytellers are fully informed at every stage of the process and reinforces the sense of safety that allows storytellers to tell e and share e uniquely personal stories that, paradoxically, often have deep meaning for a wide audience. Unlike statistics, which can usefully reveal the system’s experience of the individual, stories reveal the individual’s experience of the system (Sumner, 2008). Because stories touch hearts as well as minds, they remind us of our common humanity and our shared need for compassionate and humane care. Indeed, the digital stories have been shown to promote empathy and to sow the seeds of change in student nurses and others involved in delivering healthcare (Hardy, 2007). Once released, stories are freely available for use in healthcare education and service improvement programmes via the Patient Voices website. Their brevity, authenticity and flexibility ensure that they are widely used in medical and healthcare education (Hardy, 2007), while the licence under which the stories are released ensures that the integrity of the story will be preserved and the intentions of the storyteller honoured. Stories created during a process such as that outlined above have been found to be particularly Effective, Affective and Reflective (Sumner, 2008): they provide an effective means of conveying important messages partly because they create a connection and therefore affect the viewer. Created in a spirit of reflection, these powerful, short stories also prompt reflection in others, inviting them to consider their own practice, whatever that practice may be, in the light of the storyteller’s experience.
discussed by Huynh et al. (2008) who recognise that ignoring the impact of emotional labour can result in nurses employing defensive strategies to enable them to maintain emotional distance from their patients. The research on this issue in relation to professional socialisation implies that newly qualified nurses are encouraged by organisational culture to ignore this aspect of their work in order to prioritise practical tasks (Mackintosh, 2006). These stories illustrate the personal impact on nurses of engaging on an emotional level with their patients and shed light on how this may become burdensome if ignored or unexplored. The final issue relates to the emotional consequences of distressing events occurring in practice (illustrated by Vicky Baldwin’s ‘Maybe this just isn’t the right job for you’ available at www. patientvoices.org.uk/un.htm). In these stories, newly qualified nurses described distressing incidents in their work and reflected on how these situations impacted upon them emotionally. These events represented extreme illustrations of emotional labour and storytellers’ reflections mirrored those typical of reactions to traumatic experiences. Despite this, there appeared to be a lack of recognition from within the service of the longer-term consequences of these experiences on individual nurses. As a result the newly qualified nurses became embarrassed by their reactions and felt the need to present themselves to others as coping, a response that reflects Goffman’s (1959) view about how people negotiate daily life and make conscious decisions about how they present themselves in the public arena. Goffman refers to creating a ‘front’ or image of oneself as an acceptable person and argues that such impression management is a fundamental component of all social interaction. These stories illustrate the ways in which the newly qualified nurse responds to expectations in order to evoke confirmatory feedback which may lead to the verification of conceptions about how they should behave as ‘professionals’ which, in turn, ultimately involves attempts to “switch off” emotions (Clouder, 2003).
3. Phase 1: the stories that emerged
4. Evaluation of the storytellers’ experiences of the digital storytelling process
Whilst the digital stories that were created do not claim to be representative of all newly qualified nurses’ experiences, the content of the stories is supported by events reported in the wider research literature exploring this transition process. These digital stories reiterated the overarching impact of a reality shock stemming from the gap between expectation and actuality. However, the cause of this shock appeared to be varied and resulted from different challenges. The stories that emerged related to the following issues and concerns. Firstly, to the conflict the newly qualified nurses experienced when their values where questioned or disregarded by established nurses (illustrated by Susanna Morris’ story, ‘Who is an expert?’ available at www.patientvoices.org.uk/un.htm). This situation appeared to result in the newly qualified nurses questioning their personal beliefs and identity as nurses due to lack of support and dismissal from those they were looking to for guidance. Discussions within the literature regarding how values are shaped by the professional socialisation process are reflected in these stories (Fagermoen, 1997; Mackintosh, 2006). The stories present detailed reflections on the potential consequences of negative interactions with established nurses while offering powerful illustrations of horizontal violence uncovered in previous research (Randle, 2003; Longo, 2007). A further issue related to the challenges of the therapeutic relationship (Illustrated by Rachel Hadland’s ‘Are we there yet?’ available at www.patientvoices.org.uk/un.htm). The content of these stories relates closely to the concept of emotional labour, which refers to the internal regulation of emotions required of nurses in order to adopt a ‘work persona’ which still enables them to express their (surface or deep) emotions during patient encounters. This concept has been
The storytellers were invited to take part in a focus group discussion to consider their experiences of the digital storytelling process. The focus groups were facilitated and analysed by the first author. A thematic content analysis was conducted, which involved identifying common views and perspectives expressed by the participants. The themes that were generated were presented to the participants who verified that they were representative of their experience. The focus group participants gave written permission for extracts from the focus group to be included in subsequent publications. The group considered their motivation to create a digital story and take part in the storytelling process. The most significant motivation appeared to be underpinned by a desire to take the opportunity to reflect on their experiences. One participant stated: ‘Just to take a breath and think about that [incident] intensively for a couple of days meant a lot. I could have just carried on and on and on and not really processed it, whereas I was able to get away from work and talk about it.’ For other storytellers, the opportunity to create a teaching resource which would communicate an important message was a motivating factor. These individuals felt dissatisfied with their own experiences of the transition process and passionate about making a difference for others. They identified the digital story medium as a way of expressing their experiences in a manner which would command the attention of educators, service managers and even policy makers. Despite these motivating factors, the storytellers found the process challenging for a number of reasons. Firstly, some felt
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conflict with disclosure of their personal experiences into the public arena. They felt this placed them in a vulnerable position as they were allowing others to judge them, their feelings and their practice. For example: ‘I was worried about how people may judge my practice and what was the message they would take from the story.’ The storytellers also reflected on how surprised they were by the emotional consequence of the process. Whilst they identified this as a challenge, they also described it as a benefit, as they felt this was due to the depth of reflection that they engaged in. This was helped by them gaining validation on their reaction to events from sharing with others. One storyteller reflected: ‘When you speak about it you are quite detached e I speak about it but I’m not really thinking e it’s just words. Whereas this made me stop and think for a longer period of time, away from work, with people who are nothing to do with my work, this was good, to validate my experience. It was really helpful.’ The storytellers were also reminded of how difficult their experiences had been and realised how they had already become detached from certain emotional elements of their work through exposure and self-protection. They felt the storytelling process would enable them to maintain an awareness of challenges and encourage them to offer support to future newly qualified nurses as they developed through their career. 5. Phase 2: designing the learning environment The second phases of the educational development involved a group of five educationalists with varied expertise in utilising technological resources in education, developing safe learning environments for addressing personal development issues and promoting skills for reflective practice. Additionally a member of the University counselling service attended to provide advice on approaches to developing self efficacy and making links with the personal development workshops currently provided by the counselling services. A focus group discussion was initially facilitated to explore the group’s impressions of the stories, their views on the potential use of the stories and any concerns they had about the proposed development. The group commented on the power of the medium of digital storytelling and the stories’ ability to communicate significant messages in a short time. They felt that the content of the stories reflected their experiences of the difficulties reported by newly qualified nurses and reemphasised to them the vulnerability of the newly qualified nurse. ‘I think you got over some really, really complex and subtle messages in a beautifully simple, well-crafted way.’ (Counsellor) ‘I think, you read it all the time and I’ve seen it in surveys but I don’t think I’ve seen anything as powerful how it comes across in the stories.’ (Educationalist e Technology) ‘It really communicates their vulnerability in the workplace, you sort of think, four years, all that training, they’ll be prepared for anything, but, well, they’re nothing like prepared.’ (Educationalist e Reflective practice)
start opening the discussion up.’ (Educationalist e Personal development) ‘There’s huge implications though for the teachers. Because there is a whole issue about managing students and emotional safety. You’ve got to think about the teachers skills in doing this and the teachers’ emotional safety as well.’ (Educationalist e Personal development) Despite the recognition that the emotional content of the stories presented a challenge to the facilitators, it was felt that the educational experience resulting from showing the stories would be extremely valuable. This was due to their power to acknowledge and uncover the emotional vulnerability of the student group which some felt was not recognised and therefore forced students to develop negative coping strategies that are modelled and continually replicated in practice. ‘But it’s about somehow acknowledging that, it’s almost inevitable that there’s going to be times when you’re going to hear something that’s going to press your buttons and be tough for you to deal with, and that’s okay, but it is important to deal with it, not to just squash it down, because often you get a group of people together who cope with awful things by pulling the shutters down, do the defensive thing, you give the message that you’ve got to tough it out.’ (Counsellor) Following the focus group discussion, the group designed the environment which would enable a safe, supportive and reflective learning process to be initiated by the digital stories. A workshop format was recommended to take place over one day with up to 15 students and a facilitators guide was developed. Additionally, preparation sessions for facilitators were planned to enable skills development and discussion of how student’s vulnerabilities could be safely explored within the classroom environment. 6. Phase 3: implementation and evaluation of the educational development Phase 3 of the educational development involved implementing and evaluating the workshops with 58 students in the final module of their pre-registration program. The students were asked to complete a semi-structured questionnaire to gain insight into their experience of taking part in the workshop. All 58 students who took part in the workshop completed the questionnaire. Below are some of the comments made by students to illustrate their perspective of the learning process. There were a number of comments which related to the authenticity of the stories which appeared to enable students to relate to the storyteller. ‘It made my learning more meaningful and real.’ ‘I felt many newly-qualified nurses would feel the same way and it helps to hear first hand from someone in a real life situation.’ ‘It made the session come to life.’ The students also acknowledged how it raised issues that were of concern to them. This presented a challenge to some members of the group. However, it does support the hope that the stories can be used as a means of exposing students to some of the challenges the may encounter in a safe and supportive environment before the encounter them in practice where support may be less available.
There was a consensus that the stories should be used in sensitive and safe environments, due to the potential emotional impact they may have on the student. While this was recognised as a strength of the stories, there were concerns about the implications for the skills and confidence of the lecturers.
‘It raised issues and problems which I had been thinking about in the back of my mind.’ ‘I felt sympathy for the storyteller and fearful for my own progression to a qualified nurse in relation to the responsibility.’ ‘It was a good way of discussing these issues and to identify your own that you perhaps hadn’t realised you had until this.’
‘I think we have a moral responsibility to keep students safe and often you don’t know what you’re letting yourselves in for until you
Students commented on the reassurance they gained from sharing their concerns with others and realising that others had
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similar concerns through the group discussions. This suggests that the workshop also had a supportive function. ‘It helps you to realise the things you worry about are what others go through too, so you’re not alone.’ ‘I now realise that other people have the same worries as me and that most people are feeling the same as I am.’ ‘It’s good to know I am not alone when I feel my confidence is not as high as it could be.’ The authenticity of the stories and reflective discussions also appeared to enable the students to place themselves in the position of the newly qualified nurse and consider how they might respond to the challenges faced. This indicates that the students were starting to recognise their personal resources that would enable them to regain a feeling of control. ‘I recognised the fears, values and first expectations that the storyteller had as what I would have. It was encouraging to see how she dealt with them and that I am not on my own.’ ‘I felt I could relate to the feelings she was experiencing. It made me look at how I would deal with that scenario.’ ‘Makes you think about how you would act in this situation which is good as it challenges your values and ideas.’ ‘I appreciated thinking about strategies for conflict resolution and gaining a wider experience of seeing the points of view of others.’ The students were asked to compare this experience to other teaching approaches which aimed to encourage reflective learning. The students identified that the open structure of the workshop gave them space to reflect whereas other approaches focused more on teaching reflective models. They also identified that the storytellers were modelling the reflective process, enabling them to observe reflection in action. Some students noted that this helped them to go onto reflect on their own experiences. ‘Normal reflection sessions are set out and structured. I felt able to explore more.’ ‘I have always struggled with reflection but listening to someone else reflect made me also reflect.’ ‘A lot better, more interactive and helped me to reflect in a deeper and more meaningful way.’ ‘Probably the most I have reflected on anything as I was able to put myself in Susanna’s shoes as she was the one telling the story, not just reading it.’ 7. Discussion: a different kind of story The distillation of experiences and emotions into a short digital story that has ‘clarity, purity and potency’ (Patient Voices, 2009) appeared to offer profound opportunities for learning and growth for the newly qualified nurse storytellers. The opportunity for reflection and creative consideration of strategies that might enable the student viewers to cope in similar situations leads to the kind of transformative learning that occurs as we understand and seek to be understood in a dialogue that allows for ‘redefinition through reflection and the accretion of new layers of meaning’ (Mezirow, 1991). This project bears out the findings in an earlier study which concluded that ‘the creation and use of digital stories, through careful facilitation, offers storytellers and viewers the opportunity to grasp and transform their experiences and, in so doing, participate more fully in the community, learning from peers and colleagues rather than from experts’ (Hardy, 2007). The opportunity to exchange stories and engage in such a dialogue at this stage in their nursing career is likely to both ease and
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hasten the journey to qualified nurse. Full participation is, in turn, likely to ensure the kind of support and sense of belonging that has been highlighted by students and newly qualified nurses alike as an important factor in the transition process. The digital stories are one way of helping student nurses become more conversant with the ‘activities, identities, artefacts and communities of knowledge and practice’ (Lave and Wenger, 1991) that will help them master the knowledge and skill they need to take up their place in the nursing community. It has been traditional to think of the stages of learning as articulated by Kolb in his Learning Cycle (Kolb, 1984) (see Fig. 1) and it may be helpful to consider the stages of this project in relation to Kolb’s model. 1) The newly qualified nurses’ stories are grounded in concrete experience. 2) Observation and reflection are essential elements in the creation of the stories, while sharing the stories allows others to observe and reflect. 3) After seeing and reflecting on the stories, abstract concepts are formed about, for example, coping strategies. 4) These concepts can be tested out, initially in the workshop context and later, when concrete experiences in the early days of practice will provide plenty of new situations for reflection and observation. and so the cycle continues. However, during this project, the authors have observed a new model of learning emerging. We have named this model, illustrated in Fig. 2, The Spiral of Growth Through Stories (SGTS), This model extrapolates from and extends Kolb’s Learning Cycle, recognising that the potential for growth and learning extends beyond the individual learner to a community of students, educationalists, preceptors and other audiences to initiate further cycles of learning. In the centre of the SGTS spiral is the concrete experience, which in this case, refers to the reality shock. The newly qualified nurses reflect on and create stories based on their experiences. Learning for storytellers takes the form of new understanding about themselves and the world in which they now work. Sharing stories offers preceptors, mentors, students, educators (and others) an opportunity to learn through gaining insights into the newly qualified nurses’ world. It is to be hoped that, as a result of seeing, and reflecting on, the stories, there will be changes in educational practice, not only for the student group, soon to be newly qualified, who are now better equipped to cope with the reality shock, but also in the practices of preceptors and educators, who now have a new set of tools with
Fig. 1. Kolb’s learning cycle.
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robust support strategies which enable newly qualified nurses to maintain the capacity to care. References
Fig. 2. Spiral of growth through stories.
which to prepare future students. The result should be different stories, stories that tell of greater resilience and more confidence in dealing with the reality shock, stories that reveal a greater capacity for empathy and more humane care for colleagues as well as patients. The Nautilus shell provides a useful metaphor for nurtured, protected, supported and organic growth through stories that are experienced, developed and shared within communities of practice.
8. Conclusion It appears that the digital stories delivered in this context offer an opportunity for students to step into the shoes of the storyteller and give insight into what can be a difficult journey, from the relatively safe and predictable world of university to the maelstrom of clinical practice. This may enable them to identify personal strategies to better manage this transition period. Careful consideration of the curriculum by educationalists to make more intentional use of these stories and others like them might enable students to be better prepared for the real world of clinical practice. Integration of the stories into mentor and preceptor preparation programmes could serve as powerful reminders of the challenges associated with becoming a nurse. It is hoped that this would result in different stories being told, stories that challenge the accepted ‘reality shock’ through the development of a core strength and
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Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Challenging the shock of reality through digital storytelling Gemma Stacey a,1, Pip Hardy b, * a b
Division of Nursing, University of Nottingham, London Road Community Hospital, London Road, Derby DE1 2QY, United Kingdom Patient Voices Programme, Pilgrim Projects Limited, 91 Waterbeach Road, Landbeach, Cambridgeshire CB25 9FA, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 9 August 2010
The transition from student to qualified nurse is widely acknowledged to entail a difficult period of adjustment, involving significant personal and professional challenges. Kramer [1974. Reality Shock e Why Nurses Leave Nursing. Mosby, St. Louis] originally described this as a “reality shock” due to the dissonance experienced between the expectations of the newly qualified nurse and the actuality of clinical practice. This experience continues to be echoed throughout the literature exploring factors influencing the quality of compassionate care, post-qualification support strategies, and attrition rates. Despite this, the phenomenon of a reality shock appears to have been accepted as an inevitable aspect of professional socialisation. This paper aims to report on an educational development which attempted to challenge these negative experiences and outcomes. The Division of Nursing at the University of Nottingham worked alongside the Patient Voices Programme (www.patientvoices.org.uk) to create reflective digital stories of newly qualified nurses. In their own words and using personal photos, the newly qualified nurses relate stories about an event that they have found particularly challenging during the transition from student to nurse. The stories were intended to provide opportunities for future students to learn and educationalists to reconsider the curriculum to facilitate preparation for the world of clinical practice. A learning environment was developed and piloted that utilises the digital stories to encourage student nurses to reflect upon the challenges of this transition by engaging with the storytellers, empathising with their experience and considering ways they might respond in similar situations. Evaluation of this educational forum suggests that the digital stories offer the audience a unique opportunity to walk in the shoes of the storyteller. As a consequence, an altered story might be told through encouraging newly qualified nurses to develop their core strengths and, in doing so, maintain their capacity to care. Ó 2010 Elsevier Ltd. All rights reserved.
Keywords: Digital stories Professional socialisation Reality shock Reflection Patient Voices
1. Literature review The evidence base that reports on the transition from student to newly qualified nurse acknowledges that it often entails a difficult period of adjustment involving many significant personal and professional challenges. Kramer (1974) originally described this phenomenon as a ‘reality shock’ and defined it as ‘the reactions of new workers when they find themselves in a work situation for which they have spent several years preparing and for which they thought they were going to be prepared, and then suddenly find they are not’. This experience continues to be echoed throughout the recent literature exploring the lack of post-qualification support strategies, low job satisfaction and high attrition rates (Robinson * Corresponding author. Tel.: þ44 7721 751784. E-mail addresses: [email protected] (G. Stacey), pip@pilgrimprojects. co.uk (P. Hardy). 1 Tel.: þ44 1332 347141x2558. 1471-5953/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2010.08.003
et al., 2005; Forsyth and McKenzie, 2006). The consequences are significant as the coping strategies that newly qualified nurses employ to rectify this dissonance are shown to have negative effects on quality of care and maintenance of person-centred values (Mackintosh, 2006). Despite this issue being reported first in 1974, the phenomenon of a ‘reality shock’ appears to remain and seems to have been accepted by education and practice as an inevitable aspect of professional socialisation. The process of professional socialisation, often described in the literature, suggests that the nursing profession exists as a powerful structural reality and that newcomers are little more than passive recipients of knowledge who are being moulded into what the profession defines as ‘good’ professionals. Clouder (2003) explains this apparent conformity in two ways: ‘learning to play the game’ and ‘presentation of self ’. Playing the game involves becoming aware of rules, both written and unwritten, and learning to comply with the systems in place. This process requires recognition of the power differentials inherent in being a newcomer seeking to join
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the profession. Clouder (2003) recognised that students perceive a need to present or act in accordance with expectations throughout the identification process. Clouder (2003) draws upon the work of Goffman (1959) who emphasises how people negotiate daily life and make conscious decisions about how they present themselves in the public arena to fit in with social practices identified by the profession. It is, therefore, vital that newcomers begin to position themselves in relation to expectations. Contemporary research into the professional socialisation of nurses has also recognised the relevance of the values that are associated with a profession. Fagermoen (1997) emphasises the importance that values and beliefs play in shaping the professional identity and consequent socialisation of a nurse, saying a nurse’s identity is defined by these values and ‘represent her philosophy of nursing,’ (p. 436). Similarly, Mackintosh (2006) identified a juxtaposition between different and opposing sets of values within nursing. Despite the assumption that a personal relationship and emotional support are essential elements of the nurse’s role, Mackintosh maintains that this emotional caring ethos is discouraged to enable nurses to prioritise-task-based care needs. The result is personal disillusionment amongst nursing students and the development of cynical attitudes about the caring aspect of their role. Maben et al. (2006) attempted to consider the specific aspects of nursing practice which may be contributing to this kind of emotional and moral distress. This research indicates that although nurses emerge from their educational programme with a strong set of professional values, a number of organisational factors sabotage their implementation. The factors at play include a lack of support, poor nursing role models, time pressure, role constraints, staff shortages and work overload. Kelly (1998) supports these themes and identified the importance of ‘preserving moral integrity’ as the basic psychosocial process when newly qualified nurses adapt to the ‘real world’ of work. She suggests moral distress results when newly qualified nurses believe they are not living up to their moral convictions and highlighted the prevalence of self-criticism and self-blame in this process. Here, newly qualified nurses become intensely aware of the discrepancy between their perceptions of good nursing and what they observe in practice. They cope with this by redefining their perceptions of their role. This process allows the student to rationalise the accepted poor nursing practices rather than questioning or confronting them. This view is supported by Mackintosh (2006) who maintains that nursing students are coping with this moral distress and identified that the minority of students recognised the practice of poor role models and rejected its influence. However, others rationalised these practices as a consequence of the working organisation or the type of service users they were working with. Some felt that the ability to ‘switch off’ from the emotional aspects of nursing practice was essential to cope with the emotional demands of the nursing role and therefore a skill which they whished to acquire. A body of evidence presents a view of how established staff may influence the experience of newly qualified nurses entering the profession. Evidence suggests poor role models who devalue care have been shown to cause personal disillusionment and have a negative influence on the maintenance of humanistic values (Greenwood, 1993; Mackintosh, 2006). Adding to this concern, several studies recognise the danger of newly qualified nurses becoming desensitised to poor nursing practice habits and adopting them as their own (Greenwood, 1993; Holland, 1999). It has been suggested that this can lead to a tendency amongst students to shift their self-identity in order to justify the loss of ideals and become proficient in their new role. Newly qualified nurses who initially challenge issues of concern are quickly discouraged if not supported by senior colleagues and so the disposition to resist may coexist with
a desire to appear to conform. It is suggested that this process will have a negative effect on newly qualified nurses, who may lose their skills as ‘knowledgeable doers’ and ‘confident analytical thinkers’ as they become socialised into a culture where routine and task-based work approaches are more highly valued (Jowett et al., 1991). Even more seriously, Brookfield (1993) referred to the term ‘cultural suicide’ in suggesting that practitioners who choose to take ‘a critical stance towards conventional assumptions and accepted procedures face the prospect of finding themselves excluded from the culture that has defined and sustained them up to that point’ (p. 200). This interpersonal conflict among nurses, termed ‘horizontal violence’, was explored by Mckenna (2003) who identified this as a significant issue confronting new graduates within the nursing profession. This is the phenomenon underpinning nurses’ references to their profession ‘eating their young’ (Longo, 2007, p. 177) referring to an act of subtle or overt aggression perpetrated by one colleague toward another colleague (Mckenna, 2003; Randle, 2003; Longo, 2007). The research evidence offers a number of explanations for the continued experience of “reality shock” and the reasons why current models of preparation for practice are not addressing the complexity of the issues. Despite this vast evidence base, it appears that there have only been limited attempts to prepare students for this difficult transition process during their pre-registration training. This paper will report on an educational development that has attempted to challenge this negative experience. The development project encompassed 3 distinct phases. Phase 1 involved the development of 8 digital stories with newly qualified nurses followed by a focus group discussion on their experiences of the story making process. Phases 2 focused on designing an educational forum for the use of the digital stories through the facilitation of a workshop with individuals who had expertise in the area. The final phase involved the implementation and evaluation of the education forum with student nurses. 2. Digital storytelling and Patient Voices We learn, according to Dewey (1938) and others, not from our experience, but by reflecting on experience. Reflection is a key skill for professionals, offering them ‘a structured means of studying processes and challenges and making connections between their personal and professional lives’ (Hardy, 2007). However, as Schön (1987) reminds us, ‘Stories are products of reflection, but we do not usually hold onto them long enough to make them objects of reflection in their own right.’ The first stage of our project, therefore, offered eight newly qualified nurses an opportunity to reflect on recent experiences through the creation of their digital stories during a three-day workshop facilitated by Pilgrim Projects’ Patient Voices Programme. The Patient Voices Programme is a social enterprise that aims to facilitate the telling and sharing of the unwritten and unspoken stories of ordinary people’s experiences of healthcare in the hope of influencing clinicians, managers and decision-makers to commission, design and deliver more compassionate and humane healthcare (Patient Voices Website) (www.patientvoices.org.uk). All of the stories in the Programme are created in small, carefully facilitated workshops. The Patient Voices methodology has been refined over the past seven years, based on the workshop process designed and developed by the Centre for Digital Storytelling (www. storycenter.org) over nearly twenty years. Using techniques drawn from creative writing, community theatre, narrative and art therapy, storytellers are gently guided through the stages of: considering the elements of a good story; sharing their initial story idea and developing it in the story circle; editing, refining and distilling the story to reveal its essence and
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discover its meaning; recording their story; selecting appropriate photos; learning the basics of image and video editing; and, finally, becoming directors of their own movies. Storytellers have control over their story at all times, and participate fully in every stage of the process that results in the finished short movie, so that the endof-workshop premier is a true celebration of a significant accomplishment, shared by storytellers and facilitators alike. A careful, two-stage consent and release process ensures that storytellers are fully informed at every stage of the process and reinforces the sense of safety that allows storytellers to tell e and share e uniquely personal stories that, paradoxically, often have deep meaning for a wide audience. Unlike statistics, which can usefully reveal the system’s experience of the individual, stories reveal the individual’s experience of the system (Sumner, 2008). Because stories touch hearts as well as minds, they remind us of our common humanity and our shared need for compassionate and humane care. Indeed, the digital stories have been shown to promote empathy and to sow the seeds of change in student nurses and others involved in delivering healthcare (Hardy, 2007). Once released, stories are freely available for use in healthcare education and service improvement programmes via the Patient Voices website. Their brevity, authenticity and flexibility ensure that they are widely used in medical and healthcare education (Hardy, 2007), while the licence under which the stories are released ensures that the integrity of the story will be preserved and the intentions of the storyteller honoured. Stories created during a process such as that outlined above have been found to be particularly Effective, Affective and Reflective (Sumner, 2008): they provide an effective means of conveying important messages partly because they create a connection and therefore affect the viewer. Created in a spirit of reflection, these powerful, short stories also prompt reflection in others, inviting them to consider their own practice, whatever that practice may be, in the light of the storyteller’s experience.
discussed by Huynh et al. (2008) who recognise that ignoring the impact of emotional labour can result in nurses employing defensive strategies to enable them to maintain emotional distance from their patients. The research on this issue in relation to professional socialisation implies that newly qualified nurses are encouraged by organisational culture to ignore this aspect of their work in order to prioritise practical tasks (Mackintosh, 2006). These stories illustrate the personal impact on nurses of engaging on an emotional level with their patients and shed light on how this may become burdensome if ignored or unexplored. The final issue relates to the emotional consequences of distressing events occurring in practice (illustrated by Vicky Baldwin’s ‘Maybe this just isn’t the right job for you’ available at www. patientvoices.org.uk/un.htm). In these stories, newly qualified nurses described distressing incidents in their work and reflected on how these situations impacted upon them emotionally. These events represented extreme illustrations of emotional labour and storytellers’ reflections mirrored those typical of reactions to traumatic experiences. Despite this, there appeared to be a lack of recognition from within the service of the longer-term consequences of these experiences on individual nurses. As a result the newly qualified nurses became embarrassed by their reactions and felt the need to present themselves to others as coping, a response that reflects Goffman’s (1959) view about how people negotiate daily life and make conscious decisions about how they present themselves in the public arena. Goffman refers to creating a ‘front’ or image of oneself as an acceptable person and argues that such impression management is a fundamental component of all social interaction. These stories illustrate the ways in which the newly qualified nurse responds to expectations in order to evoke confirmatory feedback which may lead to the verification of conceptions about how they should behave as ‘professionals’ which, in turn, ultimately involves attempts to “switch off” emotions (Clouder, 2003).
3. Phase 1: the stories that emerged
4. Evaluation of the storytellers’ experiences of the digital storytelling process
Whilst the digital stories that were created do not claim to be representative of all newly qualified nurses’ experiences, the content of the stories is supported by events reported in the wider research literature exploring this transition process. These digital stories reiterated the overarching impact of a reality shock stemming from the gap between expectation and actuality. However, the cause of this shock appeared to be varied and resulted from different challenges. The stories that emerged related to the following issues and concerns. Firstly, to the conflict the newly qualified nurses experienced when their values where questioned or disregarded by established nurses (illustrated by Susanna Morris’ story, ‘Who is an expert?’ available at www.patientvoices.org.uk/un.htm). This situation appeared to result in the newly qualified nurses questioning their personal beliefs and identity as nurses due to lack of support and dismissal from those they were looking to for guidance. Discussions within the literature regarding how values are shaped by the professional socialisation process are reflected in these stories (Fagermoen, 1997; Mackintosh, 2006). The stories present detailed reflections on the potential consequences of negative interactions with established nurses while offering powerful illustrations of horizontal violence uncovered in previous research (Randle, 2003; Longo, 2007). A further issue related to the challenges of the therapeutic relationship (Illustrated by Rachel Hadland’s ‘Are we there yet?’ available at www.patientvoices.org.uk/un.htm). The content of these stories relates closely to the concept of emotional labour, which refers to the internal regulation of emotions required of nurses in order to adopt a ‘work persona’ which still enables them to express their (surface or deep) emotions during patient encounters. This concept has been
The storytellers were invited to take part in a focus group discussion to consider their experiences of the digital storytelling process. The focus groups were facilitated and analysed by the first author. A thematic content analysis was conducted, which involved identifying common views and perspectives expressed by the participants. The themes that were generated were presented to the participants who verified that they were representative of their experience. The focus group participants gave written permission for extracts from the focus group to be included in subsequent publications. The group considered their motivation to create a digital story and take part in the storytelling process. The most significant motivation appeared to be underpinned by a desire to take the opportunity to reflect on their experiences. One participant stated: ‘Just to take a breath and think about that [incident] intensively for a couple of days meant a lot. I could have just carried on and on and on and not really processed it, whereas I was able to get away from work and talk about it.’ For other storytellers, the opportunity to create a teaching resource which would communicate an important message was a motivating factor. These individuals felt dissatisfied with their own experiences of the transition process and passionate about making a difference for others. They identified the digital story medium as a way of expressing their experiences in a manner which would command the attention of educators, service managers and even policy makers. Despite these motivating factors, the storytellers found the process challenging for a number of reasons. Firstly, some felt
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conflict with disclosure of their personal experiences into the public arena. They felt this placed them in a vulnerable position as they were allowing others to judge them, their feelings and their practice. For example: ‘I was worried about how people may judge my practice and what was the message they would take from the story.’ The storytellers also reflected on how surprised they were by the emotional consequence of the process. Whilst they identified this as a challenge, they also described it as a benefit, as they felt this was due to the depth of reflection that they engaged in. This was helped by them gaining validation on their reaction to events from sharing with others. One storyteller reflected: ‘When you speak about it you are quite detached e I speak about it but I’m not really thinking e it’s just words. Whereas this made me stop and think for a longer period of time, away from work, with people who are nothing to do with my work, this was good, to validate my experience. It was really helpful.’ The storytellers were also reminded of how difficult their experiences had been and realised how they had already become detached from certain emotional elements of their work through exposure and self-protection. They felt the storytelling process would enable them to maintain an awareness of challenges and encourage them to offer support to future newly qualified nurses as they developed through their career. 5. Phase 2: designing the learning environment The second phases of the educational development involved a group of five educationalists with varied expertise in utilising technological resources in education, developing safe learning environments for addressing personal development issues and promoting skills for reflective practice. Additionally a member of the University counselling service attended to provide advice on approaches to developing self efficacy and making links with the personal development workshops currently provided by the counselling services. A focus group discussion was initially facilitated to explore the group’s impressions of the stories, their views on the potential use of the stories and any concerns they had about the proposed development. The group commented on the power of the medium of digital storytelling and the stories’ ability to communicate significant messages in a short time. They felt that the content of the stories reflected their experiences of the difficulties reported by newly qualified nurses and reemphasised to them the vulnerability of the newly qualified nurse. ‘I think you got over some really, really complex and subtle messages in a beautifully simple, well-crafted way.’ (Counsellor) ‘I think, you read it all the time and I’ve seen it in surveys but I don’t think I’ve seen anything as powerful how it comes across in the stories.’ (Educationalist e Technology) ‘It really communicates their vulnerability in the workplace, you sort of think, four years, all that training, they’ll be prepared for anything, but, well, they’re nothing like prepared.’ (Educationalist e Reflective practice)
start opening the discussion up.’ (Educationalist e Personal development) ‘There’s huge implications though for the teachers. Because there is a whole issue about managing students and emotional safety. You’ve got to think about the teachers skills in doing this and the teachers’ emotional safety as well.’ (Educationalist e Personal development) Despite the recognition that the emotional content of the stories presented a challenge to the facilitators, it was felt that the educational experience resulting from showing the stories would be extremely valuable. This was due to their power to acknowledge and uncover the emotional vulnerability of the student group which some felt was not recognised and therefore forced students to develop negative coping strategies that are modelled and continually replicated in practice. ‘But it’s about somehow acknowledging that, it’s almost inevitable that there’s going to be times when you’re going to hear something that’s going to press your buttons and be tough for you to deal with, and that’s okay, but it is important to deal with it, not to just squash it down, because often you get a group of people together who cope with awful things by pulling the shutters down, do the defensive thing, you give the message that you’ve got to tough it out.’ (Counsellor) Following the focus group discussion, the group designed the environment which would enable a safe, supportive and reflective learning process to be initiated by the digital stories. A workshop format was recommended to take place over one day with up to 15 students and a facilitators guide was developed. Additionally, preparation sessions for facilitators were planned to enable skills development and discussion of how student’s vulnerabilities could be safely explored within the classroom environment. 6. Phase 3: implementation and evaluation of the educational development Phase 3 of the educational development involved implementing and evaluating the workshops with 58 students in the final module of their pre-registration program. The students were asked to complete a semi-structured questionnaire to gain insight into their experience of taking part in the workshop. All 58 students who took part in the workshop completed the questionnaire. Below are some of the comments made by students to illustrate their perspective of the learning process. There were a number of comments which related to the authenticity of the stories which appeared to enable students to relate to the storyteller. ‘It made my learning more meaningful and real.’ ‘I felt many newly-qualified nurses would feel the same way and it helps to hear first hand from someone in a real life situation.’ ‘It made the session come to life.’ The students also acknowledged how it raised issues that were of concern to them. This presented a challenge to some members of the group. However, it does support the hope that the stories can be used as a means of exposing students to some of the challenges the may encounter in a safe and supportive environment before the encounter them in practice where support may be less available.
There was a consensus that the stories should be used in sensitive and safe environments, due to the potential emotional impact they may have on the student. While this was recognised as a strength of the stories, there were concerns about the implications for the skills and confidence of the lecturers.
‘It raised issues and problems which I had been thinking about in the back of my mind.’ ‘I felt sympathy for the storyteller and fearful for my own progression to a qualified nurse in relation to the responsibility.’ ‘It was a good way of discussing these issues and to identify your own that you perhaps hadn’t realised you had until this.’
‘I think we have a moral responsibility to keep students safe and often you don’t know what you’re letting yourselves in for until you
Students commented on the reassurance they gained from sharing their concerns with others and realising that others had
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similar concerns through the group discussions. This suggests that the workshop also had a supportive function. ‘It helps you to realise the things you worry about are what others go through too, so you’re not alone.’ ‘I now realise that other people have the same worries as me and that most people are feeling the same as I am.’ ‘It’s good to know I am not alone when I feel my confidence is not as high as it could be.’ The authenticity of the stories and reflective discussions also appeared to enable the students to place themselves in the position of the newly qualified nurse and consider how they might respond to the challenges faced. This indicates that the students were starting to recognise their personal resources that would enable them to regain a feeling of control. ‘I recognised the fears, values and first expectations that the storyteller had as what I would have. It was encouraging to see how she dealt with them and that I am not on my own.’ ‘I felt I could relate to the feelings she was experiencing. It made me look at how I would deal with that scenario.’ ‘Makes you think about how you would act in this situation which is good as it challenges your values and ideas.’ ‘I appreciated thinking about strategies for conflict resolution and gaining a wider experience of seeing the points of view of others.’ The students were asked to compare this experience to other teaching approaches which aimed to encourage reflective learning. The students identified that the open structure of the workshop gave them space to reflect whereas other approaches focused more on teaching reflective models. They also identified that the storytellers were modelling the reflective process, enabling them to observe reflection in action. Some students noted that this helped them to go onto reflect on their own experiences. ‘Normal reflection sessions are set out and structured. I felt able to explore more.’ ‘I have always struggled with reflection but listening to someone else reflect made me also reflect.’ ‘A lot better, more interactive and helped me to reflect in a deeper and more meaningful way.’ ‘Probably the most I have reflected on anything as I was able to put myself in Susanna’s shoes as she was the one telling the story, not just reading it.’ 7. Discussion: a different kind of story The distillation of experiences and emotions into a short digital story that has ‘clarity, purity and potency’ (Patient Voices, 2009) appeared to offer profound opportunities for learning and growth for the newly qualified nurse storytellers. The opportunity for reflection and creative consideration of strategies that might enable the student viewers to cope in similar situations leads to the kind of transformative learning that occurs as we understand and seek to be understood in a dialogue that allows for ‘redefinition through reflection and the accretion of new layers of meaning’ (Mezirow, 1991). This project bears out the findings in an earlier study which concluded that ‘the creation and use of digital stories, through careful facilitation, offers storytellers and viewers the opportunity to grasp and transform their experiences and, in so doing, participate more fully in the community, learning from peers and colleagues rather than from experts’ (Hardy, 2007). The opportunity to exchange stories and engage in such a dialogue at this stage in their nursing career is likely to both ease and
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hasten the journey to qualified nurse. Full participation is, in turn, likely to ensure the kind of support and sense of belonging that has been highlighted by students and newly qualified nurses alike as an important factor in the transition process. The digital stories are one way of helping student nurses become more conversant with the ‘activities, identities, artefacts and communities of knowledge and practice’ (Lave and Wenger, 1991) that will help them master the knowledge and skill they need to take up their place in the nursing community. It has been traditional to think of the stages of learning as articulated by Kolb in his Learning Cycle (Kolb, 1984) (see Fig. 1) and it may be helpful to consider the stages of this project in relation to Kolb’s model. 1) The newly qualified nurses’ stories are grounded in concrete experience. 2) Observation and reflection are essential elements in the creation of the stories, while sharing the stories allows others to observe and reflect. 3) After seeing and reflecting on the stories, abstract concepts are formed about, for example, coping strategies. 4) These concepts can be tested out, initially in the workshop context and later, when concrete experiences in the early days of practice will provide plenty of new situations for reflection and observation. and so the cycle continues. However, during this project, the authors have observed a new model of learning emerging. We have named this model, illustrated in Fig. 2, The Spiral of Growth Through Stories (SGTS), This model extrapolates from and extends Kolb’s Learning Cycle, recognising that the potential for growth and learning extends beyond the individual learner to a community of students, educationalists, preceptors and other audiences to initiate further cycles of learning. In the centre of the SGTS spiral is the concrete experience, which in this case, refers to the reality shock. The newly qualified nurses reflect on and create stories based on their experiences. Learning for storytellers takes the form of new understanding about themselves and the world in which they now work. Sharing stories offers preceptors, mentors, students, educators (and others) an opportunity to learn through gaining insights into the newly qualified nurses’ world. It is to be hoped that, as a result of seeing, and reflecting on, the stories, there will be changes in educational practice, not only for the student group, soon to be newly qualified, who are now better equipped to cope with the reality shock, but also in the practices of preceptors and educators, who now have a new set of tools with
Fig. 1. Kolb’s learning cycle.
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robust support strategies which enable newly qualified nurses to maintain the capacity to care. References
Fig. 2. Spiral of growth through stories.
which to prepare future students. The result should be different stories, stories that tell of greater resilience and more confidence in dealing with the reality shock, stories that reveal a greater capacity for empathy and more humane care for colleagues as well as patients. The Nautilus shell provides a useful metaphor for nurtured, protected, supported and organic growth through stories that are experienced, developed and shared within communities of practice.
8. Conclusion It appears that the digital stories delivered in this context offer an opportunity for students to step into the shoes of the storyteller and give insight into what can be a difficult journey, from the relatively safe and predictable world of university to the maelstrom of clinical practice. This may enable them to identify personal strategies to better manage this transition period. Careful consideration of the curriculum by educationalists to make more intentional use of these stories and others like them might enable students to be better prepared for the real world of clinical practice. Integration of the stories into mentor and preceptor preparation programmes could serve as powerful reminders of the challenges associated with becoming a nurse. It is hoped that this would result in different stories being told, stories that challenge the accepted ‘reality shock’ through the development of a core strength and
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