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Responsible but unprepared: Experiences of newly educated nurses in hospital care
Nurse Education in Practice xxx (2014) 1e6
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Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Learning and teaching in clinical practice
Responsible but unprepared: Experiences of newly educated nurses in hospital care Liv-Helen Odland a, *, Torild Sneltvedt a, Venke Sörlie b a b
University of Nordland, Faculty of Professional Studies, 8049 Bodø, Norway Lovisenberg Deaconal University College, Oslo, Norway
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 10 May 2014
The purpose of this study was to highlight the experience of being newly educated nurses working in internal medicine and surgical units. The nurses were asked to recount their initial work experiences using a narrative approach. A phenomenological hermeneutic method developed for life experience research was applied in the analyses. The study participants were surprised by the discrepancy between the ideals and the theoretical and practical knowledge gained during their nursing education, and the assigned hospital tasks designated as routine care. Prominent features of this were a focus on medical diagnostics and treatment, task orientation and efficiency. Holistic nursing was not felt to be a priority within the unit. This led to frustration and feelings of inadequacy and unpreparedness. They also felt that the responsibility was overwhelming. The findings described are discussed in the context of related publications. Ó 2014 Published by Elsevier Ltd.
Keywords: Nurses Recently educated Hospital nursing care Unprepared Responsibility
Introduction There has been a focus on the extent to which nursing curricula are relevant to the professional realities awaiting nurses upon graduation. Both international and Norwegian studies have shown that newly educated nurses lack competence, and that entering the workforce constitutes a reality shock, with a feeling of ‘sink or swim’ often being the consequence (Kramer, 1974; Havn and Vedi, 1997). The study ‘In deep water’ about newly educated nurse’s competence when beginning practice in somatic hospital units concluded that there was a competence gap between the nurses’ and the employers’ expectations. The newly educated nurses experienced that, in their first workplaces, they had relatively limited competence in many areas. The competence gap was connected to an education gap between theory and practice, and also an introduction gap to the competences that are expected of a newly employed professional (Havn and Vedi, 1997). The study showed that, to varying degrees, employers have been able to resolve such deficiencies for newly educated nurses. Subsequent to this 1997 study, and in accordance with European regulations, the practical components of nursing education have been strengthened
* Corresponding author. E-mail address: [email protected] (L.-H. Odland).
and currently make up 50% of the total education (Havn and Vedi, 1997). Chang and Hancock (2003) found the first months of nursing to be potentially challenging and stressful for new nursing graduates in Australia. Role ambiguity was the most salient feature of role stress. Miyuki Takase (2006) found that role discrepancy was experienced by many nurses and that this partially contributed to nurses’ intentions to leave their jobs. Strauss (2009) reported that between 35% and 60% of new graduates leave their first place of employment within the first year and 57%, by the second year. A Norwegian study in the early 1990s suggested that a gap persisted between the bachelor education and the values prevailing in practice: specifically, that newly educated nurses were not encouraged to apply their learned knowledge and skills (Skaug 1994). In a more recent study, about half (51%) of professionally-active nurses indicated they were satisfied with their education when assessing this in relation to the tasks required on the job (Alsvåg, 2006). Relatively speaking, as part of their education, nursing students may be considered to have gained good practical skills gained in a broad repertoire of authentic patient situations (Sæther, 2003). Solli (2009) observed that the supervision received on the job was very much dependent on the local work situation. RN’s (Registered Nurses) experienced improvement in administrative duties, but lacked support for improving their skills in other areas.
http://dx.doi.org/10.1016/j.nepr.2014.05.005 1471-5953/Ó 2014 Published by Elsevier Ltd.
Please cite this article in press as: Odland, L.-H., et al., Responsible but unprepared: Experiences of newly educated nurses in hospital care, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.05.005
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L.-H. Odland et al. / Nurse Education in Practice xxx (2014) 1e6
Study purpose The purpose of this study was to highlight the experience of being newly educated nurses working in internal medicine and surgical units. Methods Design A phenomenological hermeneutical approach was chosen using narrative interviews and text analysis related to the study objectives (Lindseth and Norberg, 2004). Participants and setting Eight newly educated nurses (7 females and 1 male; aged 23e 32) working in internal medicine and surgical units at a hospital in Norway participated in the study. They had been employed for 9e 16 months. During their nursing education they had practiced as students for a period of 8 weeks in similar units. The criteria for selection were that they had practised nursing for a period up to 16 months (newly educated). All newly educated nurses were invited orally and in writing by the authors to participate in the study. Thus they were provided access through circulation of a request for participation. The first 8 that showed their interest were included in the study. For reasons of confidentiality more individual characteristics will not be described. Data collection In order to keep the study focus broad and to obtain as much information as possible, narrative interviews were conducted (Lindseth and Norberg, 2004). The nurses were asked to describe their experiences of being a newly educated nurse working on internal medicine and surgical units. During the interviews, followup questions were asked in order to acquire a deeper understanding when something remained unclear. The interviews were carried out by author one and two. The individual interviews were conducted at the nurses’ workplace in a separate meeting room, lasted for 60 min and were recorded and transcribed verbatim.
three stages. This method has been developed at The University of Tromsø and The University of Umeå, and has previously been used by different authors (Lindseth et al., 1994; Sørlie et al., 2001; Norberg et al., 2001). It has also been used in a study involving surgical units (Torjul et al., 2005). The first step is a superficial (naive) reading of the text as a whole in order to gain an overall impression and an initial grasp of the text. This naive reading shows the direction the structural analysis should take. The structural analysis (Results), in which one separates the text into meaningful units, consisting of a part of a sentence, a whole sentence, and sometimes several sentences, focuses on how information is organized to help explain what the text is saying. It includes a variety of examinations of parts of the text in order to validate or refute the initial understanding obtained from the naive reading. The meaningful units are condensed and discussed between the authors, with the purpose of identifying themes and subthemes. In this process the impression gained from the naive reading is either confirmed or disconfirmed. The third phase e the interpreted whole/comprehensive understanding (Discussion) e is an in-depth understanding based on the authors’ preunderstanding, naive reading, the structural analysis, and new read-through in which the understanding is developed using relevant theory and previous research. Validity and reliability The authors have different health-care backgrounds (public health nurse, anaesthetic nurse and intensive care nurse), and experience in internal medicine and surgical units. This provides varied perspectives and a solid knowledge base. This strengthened our study by allowing an ‘inside’ as well as an ‘outside’ perspective. The interviews provided an extensive amount of information and reflection upon newly educated nurses’ experiences. The interviews which were transcribed verbatim, read by the authors, and the structured analysis was agreed upon. The analysis was performed by the first author and discussed among the authors in order to reach conclusions. Results
Ethical considerations
To be unprepared
The project was assessed by The Regional Ethics Committee and considered to be outside the remit of the Act on Medical and Health Research (2011). It could, therefore, be implemented without the approval from the Regional Committee for Medical Research Ethics. The hospital leadership by the Chief Medical Doctor gave permission for the study. All participants gave their written, informed consent with the understanding that they had the option to withdraw at any given time. All the information collected is considered confidential and is reported anonymously. Each respondent gave permission for the conversation to be tape recorded; the taperecording to be deleted after the study has been published.
The nurses said they were not prepared for their professional work as they anticipated, even though the biggest component of their practical training had taken place in internal medicine and surgical units. The orientation period depended on the personal situation in the unit. Their experiences varied from having three duties at the beginning while being mentored by an experienced nurse to having a four weeks training period and then being mentored by an experienced nurse for one year. It happened that it was impossible to get an introductory program because of lack of personnel. This could lead to a feeling like; .. to be cast out into a different reality and feeling unprepared.
Data analysis The interviews were analysed and interpreted using a method of interpretation inspired by Ricoeur’s phenomenological hermeneutics (Lindseth and Norberg, 2004). This method focuses on the meaning of people’s narrated lived experiences. The interpretation proceeds through dialectical movements between understanding and explanation of the partial and the whole, and is carried out in
Nurses said that it was frightening to be inexperienced in a demanding and hectic working role, compared to their more idealistic, goal-driven educational years, and that the experience of facing multiple responsibilities and demands did not leave much room to be new and inexperienced. They felt that the experience as a new nurse was quite different from being a student when expertise and supervision were available.
Please cite this article in press as: Odland, L.-H., et al., Responsible but unprepared: Experiences of newly educated nurses in hospital care, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.05.005
L.-H. Odland et al. / Nurse Education in Practice xxx (2014) 1e6
During their first months on the job, their working days were filled with new impressions and duties, and they simply used all their energy at work. Nevertheless, the work still felt positive. It was exciting to learn a lot, and their new colleagues invited them to ask questions; The everyday working life is tough, compared to being a student with a lot of spare time and well cared for, you have to do everything by yourself e and have a lot of responsibility and so on ., but it has been interesting and I learnt a lot. .. it was hectic, very exciting and very overwhelming to be newly educated. The nurses experienced a big gap between ideals and reality in nursing practice. During the education years a great deal of emphasis had been placed on ideals and high quality in nursing practice;
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overall responsibility for patients and their relatives in their colleagues’ hands; There are people around all the time you can ask for support, but you have the main responsibility yourself.
To be responsible A major theme in the nurses’ narratives was that the transition from being a student to being a nurse was characterized by an overwhelming feeling of responsibility; It was like oops . Today I am a registered nurse and I am responsible myself for what I am doing. To me it was a small shock.
During our education we learn the best practice, how it should be. But when you enter the practical field you find out about reality, and maybe you are not quite prepared for that. One is perhaps slightly unprepared for the practical duty.
The nurses explained that they had not had the experience of being totally responsible for their nursing practice during their education. The mentoring nurse had the full responsibility. They said that many challenges were added to their responsibility when they become a graduate nurse;
The nurses experienced a work place where medical work and efficiency was emphasized, Efficient economy was the ruling priority and they were not prepared for such a switch in priorities;
You had responsibility for things you did not know how to deal with because you had never done it before. And the demands e at the same time the demands of being efficient.
All ideals and everything we built on to be a good nurse we try to keep up, but this is very difficult to carry out in the practical field. We do a lot of medical work.
Nevertheless, they realized that newly educated nurses have to be responsible themselves. This recognition felt frightening to them;
All the time since I graduated I have been looking forward to practice good holistic nursing care, but it is not like that. Economy is the ruling priority. Nothing is said about the quality of the work we do, and nothing is said about giving Care, but a lot is said about doing the work in a shorter time. The nurses experienced work-related pressure, multiple demands and tasks, often a lack of personnel on duty and difficulty in getting all tasks done. This led to frustration; There are big challenges and you have very little experience to handle them. There are also demands and expectations about a high level of accomplishment. You simply got very frustrated and have a strong feeling of deficiency . and then I was so exhausted I just wanted to sleep. They faced big challenges without the working experience to know how to handle them. They expressed the weight of responsibility and stress they felt when a patient’s life was at stake, which was complicated by caring for seriously ill patients of their own age; Actually e there was general pressure and stress, many deaths and many young people all the time. In a way, I was too inexperienced to handle it. Most of all I wanted to escape, and after a time I went on sick leave. The nurses found it challenging to face critically ill patients and their relatives. It was difficult to know how to act and what to say; It is difficult to find the right words and talk to patients and relatives in difficult situations. The nurses felt more comfortable when they had colleagues to help and support them, but still they felt they could not leave the
Suddenly one had to stand on one’s own feet. They underlined their need for practice in assuming responsibility for tasks and duties, which are unfamiliar to them. Another overwhelming experience was when most of the more experienced nursing staff was on vacation or sick leave, and then nurses from other areas who were unacquainted with the unit happened to be on duty. In some such instances, the newly educated nurse was the only one having some understanding about the situation in the unit; .. and then I was in a way the one who was meant to have the responsibility and achieve a lot, in spite of being newly educated. When there was a shortage of personnel and experienced nurses were busy and in a hurry, improvisation in the handling of duties could be the consequence for the newly educated nurses; One learns a lot but may be not learning the right things, more like ‘we have to do it this way now because we are that busy.
The nurses had to be responsible for all types of work in the units as well as being the group leader due to absence of experienced nurses. They described that during the summer holidays a lot of the staff was new in a unit, and they had to share administrative and organizational duties for which they were not prepared. They said that they did not know much about organizing hospital work and were untrained in many procedures. This made the situations overwhelming; ..most of all I wanted to run off, just to escape, and after three months I went on sick leave. It is pretty tough to think about it, and to talk about it as well.
Please cite this article in press as: Odland, L.-H., et al., Responsible but unprepared: Experiences of newly educated nurses in hospital care, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.05.005
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Discussion As stated above, the purpose of this study was to highlight the experience of being newly educated nurses working in internal medicine and surgical units. The main results discussed are feelings of unpreparedness and surprised by responsibility. It is likely impossible to recognize and prepare for all the challenges nurses meet in their professional life. The narratives indicate that the newly educated nurses had a strong feeling of being unprepared and being cast out into a different reality. This implies a need for new work place introductory programs (Morrow, 2009). From the evidence presented, an organized transition program to the graduate nurse role seemed to be missing. Orientation programs are reported to be very useful for newly educated nurses (Cockerham et al., 2011). The nurses interviewed perceived their start as professional nurses in hospital units to have only minor links to the practical component in their education. They experienced that hospital practice and reality differed from what they learned (Maben et al., 2006). Their lived experiences and learning during their theoretical and practical education did not enable them to feel well-enough prepared for the professional job in hospital units. Problems connected to education-to-job transition are well known (Morrow, 2009; Boychuk Duchscher and Cowan, 2004; Thidemann, 2005; Bisholt, 2011). The nurses in this study had been taught to embrace the best ideals and practices of good nursing, namely: to care for patients implies being aware of patient’s physical, mental, social and spiritual character. Based on this, nursing care integrates both practical, relational and ethical attitudes and actions, including responsibility for the most weak and vulnerable among us (Martinsen, 2003). The newly educated nurses were looking forward to put into practice good nursing care, but found it very difficult to achieve this in the hospital setting. They were cast out like in a different reality in a practical field without a satisfying transition program to help them being professionals. Although nurses have to set priorities everyday, the newly educated nurses were not experienced and they needed to develop professional judgement to develop this skill. In the hospital, medical treatment had priority and good nursing care was often forfeited. The newly educated nurses found it frightening to be inexperienced in a hectic working situation. They reported a big difference between what they had developed as their professional identity during education, and what was demanded in hospital practice of them as professionals (Thidemann, 2005). This represents a gap between two different values in the same discipline (Skaug, 1994, Maben et al., 2006). They felt that the values acquired from nursing education represent ideals and knowledge about performing the best caring, while values in hospital care are primary based on curing and cost-effectiveness. This is in accordance with what is described by Havn and Vedi (1997) about the transition gap. In fact, nurses’ workplace in hospital care has two different cultures; the culture of service-oriented nursing, emphasizing nursing care with its different values, and then the bureaucratic, systemoriented culture that is task oriented, emphasizing cost effectiveness. According to Orvik (2002) it is possible to learn to be bicultural, but according to our study newly educated nurses are not prepared to do that. Thidemann (2005) found that nurses experienced a dilemma when the employeer had equal demands for care, efficiency and productivity. In our study it seems like nurses experience care, and quality of nursing care, to be less valued by the employers than efficiency and productivity. Still they were excited to learn a lot, but found that their working days were filled with new impressions and duties taking all their energy.
Nurses who recently have completed their education at the bachelor level constitute novices (Benner, 1984). Their professional behaviour reflects textbook knowledge, but they need guidance to handle different situations. Clinical practice is far too complex to learn from textbooks. Practical experience and dialogue about relevant approaches to developing good practical skills in clinical work are needed (Benner, 1984). The nurses’ narratives indicate that they experienced that stress and pressure dominated their working environment. The time required for reflection to promote professional development is difficult to find (Solli, 2009; Orvik, 2002). There were complicated work challenges with focus on medical work and efficiency, and often it was difficult to find supervision and support. This was a frustrating experience for the nurses. According to Solli (2009), two out of three nurses who start their professional career in hospital care quit after one year. Turnover leads to a relatively young staff of nurses, and this reduces the possibility of newly educated nurses learning from experienced nurses. In addition to the feeling of stress in general, the newly educated nurses had to handle situations with critically ill patients whose life was at stake, many of them approximately the same age as the nurses. This is not easy. There were touching situations that forced recognition of the reality of dying, even for young people. In the narratives the nurses expressed the weight of responsibility and stress they felt in such situations. To meet relatives is another difficult part of such demanding situations and the nurses felt too inexperienced to provide the best care and comfort. There might have been colleagues to ask for advices, but as professional nurses they felt that they had to handle it themselves. In addition, every human is unique and every such situation with its human to human relationship is unique. Working with people implies always meeting between unique individuals (Henriksen and Vetlesen, 2010). There is no recipe for handling this. The nurses have to go into it and the best way to handle it will follow from every unique situation. They feel that they are thrown into it, and have to stand it or to escape. To escape is impossible. To care for suffering and vulnerable people is an important part of good nursing care (Sørlie, 2001). The nurses’ narratives indicate that besides lack of experience, nurses experienced impossibility of performing this important part of professional caring. Maybe this is not all about their lack of experience in handling such situations, but just as much about their powerlessness in the situation, workload and a different value system. Our results show that the newly educated nurses ended up dissatisfied with a nursing role they did not foresee. They were quite unprepared for the role they were forced into, and had to legitimate themselves in different areas than they were educated to do. The consequences were that they compromised their conscience and their professional identity in order to meet the demands from working place and employer (Solvoll, 2007). Nursing care needs time, space and resources, and thus requires the recognition and support of the employers. Then newly educated nurses can develop professional competence and professional pride according to their professional identity (Sneltvedt and Sørlie, 2011). Experience cannot solve all such issues, but can help in accepting what is impossible to change (Sneltvedt and Sørlie, 2011). It is not possible to be prepared for every situation in life in general or in professional life. Nursing care concerns the most vulnerable parts of human life, and theoretical knowledge alone does not define the skills needed. Newly educated nurses need mentoring from experienced nurses, and time to acquire the practical knowledge and wisdom to carry out good nursing care. This implies challenges for both nursing education and employers regarding how to strengthen both education and transition to practice in order to the development of good nursing professionals.
Please cite this article in press as: Odland, L.-H., et al., Responsible but unprepared: Experiences of newly educated nurses in hospital care, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.05.005
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The overwhelming feeling of responsibility The narratives indicate that the newly educated possessed a strong sense of responsibility. The transition from student to professional was akin to facing a different reality; they realized they had to stand on their own feet from day one. Student preparation did not address fully what professional nursing responsibilities included, and they felt unprepared and somewhat shocked. Assuming responsibility is impossible to learn from books, it is a skill that needs practical education to get familiar with, and learn how to deal with. One has to know the field of responsibility and its implications. The nurses experienced that they had a lot to learn in a hectic atmosphere, but they were learning and developing themselves very quickly as they gained work experience. One can say it is nearly impossible to be prepared for the responsibility as long as one is inexperienced in the practical situation, and not skilled in the different tasks of care. It is the nursing role to accept and learn that responsibility is a big and important part of nursing, and they have to get supervision in assuming responsibility. This has to start early in the education programmes to get acquainted with and then increase during the education. The disparity between having competence at novice level, and the responsibility it implies to work as a professional nurse makes the nurses experience the responsibility as overwhelming (Benner, 1984). Responsibility is a key concept in ethics and moral practice (Sneltvedt et al., 2009). It is a key phenomenon in human relationships especially when patients are involved (Henriksen and Vetlesen, 2010). Løgstrup (1989) holds that responsibility means that one receives special demands. Responsibility demands a piece of work, an action, a decision or whatever it is, that shall be done not for one’s own case, but for the case of others, for whom we are responsible. Martinsen (2003) views nursing care as a moral practice. From this view nurses carry out a big moral responsibility in their professional work (LaSala, 2009). Their work consists of making decisions and acting on behalf of their patient’s welfare, taking care of suffering and vulnerability. The newly educated nurses have a general education in nursing but they are too inexperienced to be familiar with all situations. However, there are concurrent demands of being efficient while being professionals and responsible for the patients. Our results show that this situation might make the responsibility frightening and burdensome for the newly educated nurses. Their colleagues might be helpful, give advice and help, but no one can take away responsibility from a given individual (Sørlie, 2001). Sickness is one of the most vulnerable situations in life. The responsibility cannot be avoided by referring to regulating conditions imposed by working life (Løgstrup, 1989; Henriksen and Vetlesen, 2010; Sneltvedt et al., 2009). Nurses are responsible for providing patients with quality care. Their professional ethical standards are based on meeting with other human beings who need them. This is experienced as stress, and the nurses feel inadequate to carry out duties they are responsible for in a proper manner (Henriksen and Vetlesen, 2010). They feel that they are in an unsatisfactory nursing role that conflicts with a nurse’s professional identity. Their own professional identity might gradually change and lead to changed comprehension of nurses’ responsibility. The traditional nursing role, implying good nursing care, might be at stake. Our results indicate that newly educated nurses have to assume a lot of responsibility to keep the unit going. During holiday season, lack of personnel, many newly graduated and many nurses who are unfamiliar with the hospital unit, they find that responsibility to run the unit is difficult. The only person with an idea of the whole situation is the newly educated nurse. This seems to be too heavy a responsibility. To be professional includes influencing policies
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governing both nursing care and own working conditions (Orvik, 2002). Novice nurses do not have that level of professional skill to influence this (Benner, 1984). Solli found a high degree of disparity between the demands nurses meet when they first start their career and how long it takes before they, in fact, have developed real competence to master such demands (Solli, 2009). As an example, developing skills to be a leader and administer nursing practice takes around three years. The employers, however, expect this competence to be present when the newly educated nurses start to work. The workload has to be adjusted to the competence level nurses have during the first years after their graduation, until they have the experience needed to develop adequate competence. Many newly educated nurses meet such a demanding workday. It makes some of them leave their profession before they have reached the competence level they could be able to achieve (Solli, 2009). Many international studies of this topic focus on the problematic transition from student to professional, similar to our study. Different models are developed to meet the problem with good strategies. The question is if there is enough focus on the postgraduate situation. A model might be developed to make students prepared for the transition during their education. Conclusions Newly educated nurses employed in hospital units experienced a different reality in relation to learned values and responsibilities. They felt unprepared and overwhelmed when asked to multi-task, with efficiency as a priority, as well having to assume major responsibilities. An ‘easing-in strategy’ is recommended. It is, however, impossible to recognize and prepare for all the challenges nurses meet in their professional life. Unpreparedness as an existential phenomenon has to be considered as part of professional life. More research has to be carried out with focus on preparedness for practice. Both educational institutions and employers must develop programs to give newly educated nurses a meaningful start to their professional life, to develop professional skills and encourage stable and skilled performers of nursing care. Acknowledgements The hospital leadership and the informants are hereby acknowledged for their participation. References Alsvåg, H., 2006. Nursing education in light of new RNS’ professional experiences. Nurs. Sci. Res. Nordic Ctries. 22, 34e38. Benner, P., 1984. From Novice to Expert e Excellence and Power in Clinical Nursing Practice. Addison-Wesley Publishing Company, Health Sciences Division, Menlo Park, California, USA. Bisholt, B.K.M., 2011. The professional socialization of recently graduated nurses e experiences of an introduction program. Nurse Educ. Today. http://dx.doi.org/ 10.2016/j.nedt.2011.04.001. Boychuk Duchscher, J.E., Cowan, L.S., 2004. The experience of marginalization in new nursing graduates. J. Psychiat. Ment. Health Nurs. 12, 387e395. Chang, E., Hancock, K., 2003. Role stress and role ambiguity in new nursing graduates in Australia. Nurs. Health Sci. 5, 155e163. Cockerham, J., Figueroa-Altmann, A., Eyster, B., Ross, C., Salamy, J., 2011. Supporting newly hired nurses: a program to increase knowledge and confidence while fostering relationships among the team. Nurs. Forum 46, 231e236. Havn, V., Vedi, C., 1997. In Deep Water e Recently Graduate Nurse’s Competence in Somatic Ward. SINTEF-IFIM, Trondheim, Norway. Henriksen, J.O., Vetlesen, A.J., 2010. Closeness and Distance (Nor). Gyldendal Akademisk, Oslo. Kramer, M., 1974. Reality Shock; Why Nurses Leave Nursing. CV Mosby, Saint Louis, Mo. LaSala, C.A., 2009. Moral accountability and integrity in nursing practice. Nurs. Clin. N. Am. 44, 423e434.
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Please cite this article in press as: Odland, L.-H., et al., Responsible but unprepared: Experiences of newly educated nurses in hospital care, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.05.005
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Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Learning and teaching in clinical practice
Responsible but unprepared: Experiences of newly educated nurses in hospital care Liv-Helen Odland a, *, Torild Sneltvedt a, Venke Sörlie b a b
University of Nordland, Faculty of Professional Studies, 8049 Bodø, Norway Lovisenberg Deaconal University College, Oslo, Norway
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 10 May 2014
The purpose of this study was to highlight the experience of being newly educated nurses working in internal medicine and surgical units. The nurses were asked to recount their initial work experiences using a narrative approach. A phenomenological hermeneutic method developed for life experience research was applied in the analyses. The study participants were surprised by the discrepancy between the ideals and the theoretical and practical knowledge gained during their nursing education, and the assigned hospital tasks designated as routine care. Prominent features of this were a focus on medical diagnostics and treatment, task orientation and efficiency. Holistic nursing was not felt to be a priority within the unit. This led to frustration and feelings of inadequacy and unpreparedness. They also felt that the responsibility was overwhelming. The findings described are discussed in the context of related publications. Ó 2014 Published by Elsevier Ltd.
Keywords: Nurses Recently educated Hospital nursing care Unprepared Responsibility
Introduction There has been a focus on the extent to which nursing curricula are relevant to the professional realities awaiting nurses upon graduation. Both international and Norwegian studies have shown that newly educated nurses lack competence, and that entering the workforce constitutes a reality shock, with a feeling of ‘sink or swim’ often being the consequence (Kramer, 1974; Havn and Vedi, 1997). The study ‘In deep water’ about newly educated nurse’s competence when beginning practice in somatic hospital units concluded that there was a competence gap between the nurses’ and the employers’ expectations. The newly educated nurses experienced that, in their first workplaces, they had relatively limited competence in many areas. The competence gap was connected to an education gap between theory and practice, and also an introduction gap to the competences that are expected of a newly employed professional (Havn and Vedi, 1997). The study showed that, to varying degrees, employers have been able to resolve such deficiencies for newly educated nurses. Subsequent to this 1997 study, and in accordance with European regulations, the practical components of nursing education have been strengthened
* Corresponding author. E-mail address: [email protected] (L.-H. Odland).
and currently make up 50% of the total education (Havn and Vedi, 1997). Chang and Hancock (2003) found the first months of nursing to be potentially challenging and stressful for new nursing graduates in Australia. Role ambiguity was the most salient feature of role stress. Miyuki Takase (2006) found that role discrepancy was experienced by many nurses and that this partially contributed to nurses’ intentions to leave their jobs. Strauss (2009) reported that between 35% and 60% of new graduates leave their first place of employment within the first year and 57%, by the second year. A Norwegian study in the early 1990s suggested that a gap persisted between the bachelor education and the values prevailing in practice: specifically, that newly educated nurses were not encouraged to apply their learned knowledge and skills (Skaug 1994). In a more recent study, about half (51%) of professionally-active nurses indicated they were satisfied with their education when assessing this in relation to the tasks required on the job (Alsvåg, 2006). Relatively speaking, as part of their education, nursing students may be considered to have gained good practical skills gained in a broad repertoire of authentic patient situations (Sæther, 2003). Solli (2009) observed that the supervision received on the job was very much dependent on the local work situation. RN’s (Registered Nurses) experienced improvement in administrative duties, but lacked support for improving their skills in other areas.
http://dx.doi.org/10.1016/j.nepr.2014.05.005 1471-5953/Ó 2014 Published by Elsevier Ltd.
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Study purpose The purpose of this study was to highlight the experience of being newly educated nurses working in internal medicine and surgical units. Methods Design A phenomenological hermeneutical approach was chosen using narrative interviews and text analysis related to the study objectives (Lindseth and Norberg, 2004). Participants and setting Eight newly educated nurses (7 females and 1 male; aged 23e 32) working in internal medicine and surgical units at a hospital in Norway participated in the study. They had been employed for 9e 16 months. During their nursing education they had practiced as students for a period of 8 weeks in similar units. The criteria for selection were that they had practised nursing for a period up to 16 months (newly educated). All newly educated nurses were invited orally and in writing by the authors to participate in the study. Thus they were provided access through circulation of a request for participation. The first 8 that showed their interest were included in the study. For reasons of confidentiality more individual characteristics will not be described. Data collection In order to keep the study focus broad and to obtain as much information as possible, narrative interviews were conducted (Lindseth and Norberg, 2004). The nurses were asked to describe their experiences of being a newly educated nurse working on internal medicine and surgical units. During the interviews, followup questions were asked in order to acquire a deeper understanding when something remained unclear. The interviews were carried out by author one and two. The individual interviews were conducted at the nurses’ workplace in a separate meeting room, lasted for 60 min and were recorded and transcribed verbatim.
three stages. This method has been developed at The University of Tromsø and The University of Umeå, and has previously been used by different authors (Lindseth et al., 1994; Sørlie et al., 2001; Norberg et al., 2001). It has also been used in a study involving surgical units (Torjul et al., 2005). The first step is a superficial (naive) reading of the text as a whole in order to gain an overall impression and an initial grasp of the text. This naive reading shows the direction the structural analysis should take. The structural analysis (Results), in which one separates the text into meaningful units, consisting of a part of a sentence, a whole sentence, and sometimes several sentences, focuses on how information is organized to help explain what the text is saying. It includes a variety of examinations of parts of the text in order to validate or refute the initial understanding obtained from the naive reading. The meaningful units are condensed and discussed between the authors, with the purpose of identifying themes and subthemes. In this process the impression gained from the naive reading is either confirmed or disconfirmed. The third phase e the interpreted whole/comprehensive understanding (Discussion) e is an in-depth understanding based on the authors’ preunderstanding, naive reading, the structural analysis, and new read-through in which the understanding is developed using relevant theory and previous research. Validity and reliability The authors have different health-care backgrounds (public health nurse, anaesthetic nurse and intensive care nurse), and experience in internal medicine and surgical units. This provides varied perspectives and a solid knowledge base. This strengthened our study by allowing an ‘inside’ as well as an ‘outside’ perspective. The interviews provided an extensive amount of information and reflection upon newly educated nurses’ experiences. The interviews which were transcribed verbatim, read by the authors, and the structured analysis was agreed upon. The analysis was performed by the first author and discussed among the authors in order to reach conclusions. Results
Ethical considerations
To be unprepared
The project was assessed by The Regional Ethics Committee and considered to be outside the remit of the Act on Medical and Health Research (2011). It could, therefore, be implemented without the approval from the Regional Committee for Medical Research Ethics. The hospital leadership by the Chief Medical Doctor gave permission for the study. All participants gave their written, informed consent with the understanding that they had the option to withdraw at any given time. All the information collected is considered confidential and is reported anonymously. Each respondent gave permission for the conversation to be tape recorded; the taperecording to be deleted after the study has been published.
The nurses said they were not prepared for their professional work as they anticipated, even though the biggest component of their practical training had taken place in internal medicine and surgical units. The orientation period depended on the personal situation in the unit. Their experiences varied from having three duties at the beginning while being mentored by an experienced nurse to having a four weeks training period and then being mentored by an experienced nurse for one year. It happened that it was impossible to get an introductory program because of lack of personnel. This could lead to a feeling like; .. to be cast out into a different reality and feeling unprepared.
Data analysis The interviews were analysed and interpreted using a method of interpretation inspired by Ricoeur’s phenomenological hermeneutics (Lindseth and Norberg, 2004). This method focuses on the meaning of people’s narrated lived experiences. The interpretation proceeds through dialectical movements between understanding and explanation of the partial and the whole, and is carried out in
Nurses said that it was frightening to be inexperienced in a demanding and hectic working role, compared to their more idealistic, goal-driven educational years, and that the experience of facing multiple responsibilities and demands did not leave much room to be new and inexperienced. They felt that the experience as a new nurse was quite different from being a student when expertise and supervision were available.
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During their first months on the job, their working days were filled with new impressions and duties, and they simply used all their energy at work. Nevertheless, the work still felt positive. It was exciting to learn a lot, and their new colleagues invited them to ask questions; The everyday working life is tough, compared to being a student with a lot of spare time and well cared for, you have to do everything by yourself e and have a lot of responsibility and so on ., but it has been interesting and I learnt a lot. .. it was hectic, very exciting and very overwhelming to be newly educated. The nurses experienced a big gap between ideals and reality in nursing practice. During the education years a great deal of emphasis had been placed on ideals and high quality in nursing practice;
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overall responsibility for patients and their relatives in their colleagues’ hands; There are people around all the time you can ask for support, but you have the main responsibility yourself.
To be responsible A major theme in the nurses’ narratives was that the transition from being a student to being a nurse was characterized by an overwhelming feeling of responsibility; It was like oops . Today I am a registered nurse and I am responsible myself for what I am doing. To me it was a small shock.
During our education we learn the best practice, how it should be. But when you enter the practical field you find out about reality, and maybe you are not quite prepared for that. One is perhaps slightly unprepared for the practical duty.
The nurses explained that they had not had the experience of being totally responsible for their nursing practice during their education. The mentoring nurse had the full responsibility. They said that many challenges were added to their responsibility when they become a graduate nurse;
The nurses experienced a work place where medical work and efficiency was emphasized, Efficient economy was the ruling priority and they were not prepared for such a switch in priorities;
You had responsibility for things you did not know how to deal with because you had never done it before. And the demands e at the same time the demands of being efficient.
All ideals and everything we built on to be a good nurse we try to keep up, but this is very difficult to carry out in the practical field. We do a lot of medical work.
Nevertheless, they realized that newly educated nurses have to be responsible themselves. This recognition felt frightening to them;
All the time since I graduated I have been looking forward to practice good holistic nursing care, but it is not like that. Economy is the ruling priority. Nothing is said about the quality of the work we do, and nothing is said about giving Care, but a lot is said about doing the work in a shorter time. The nurses experienced work-related pressure, multiple demands and tasks, often a lack of personnel on duty and difficulty in getting all tasks done. This led to frustration; There are big challenges and you have very little experience to handle them. There are also demands and expectations about a high level of accomplishment. You simply got very frustrated and have a strong feeling of deficiency . and then I was so exhausted I just wanted to sleep. They faced big challenges without the working experience to know how to handle them. They expressed the weight of responsibility and stress they felt when a patient’s life was at stake, which was complicated by caring for seriously ill patients of their own age; Actually e there was general pressure and stress, many deaths and many young people all the time. In a way, I was too inexperienced to handle it. Most of all I wanted to escape, and after a time I went on sick leave. The nurses found it challenging to face critically ill patients and their relatives. It was difficult to know how to act and what to say; It is difficult to find the right words and talk to patients and relatives in difficult situations. The nurses felt more comfortable when they had colleagues to help and support them, but still they felt they could not leave the
Suddenly one had to stand on one’s own feet. They underlined their need for practice in assuming responsibility for tasks and duties, which are unfamiliar to them. Another overwhelming experience was when most of the more experienced nursing staff was on vacation or sick leave, and then nurses from other areas who were unacquainted with the unit happened to be on duty. In some such instances, the newly educated nurse was the only one having some understanding about the situation in the unit; .. and then I was in a way the one who was meant to have the responsibility and achieve a lot, in spite of being newly educated. When there was a shortage of personnel and experienced nurses were busy and in a hurry, improvisation in the handling of duties could be the consequence for the newly educated nurses; One learns a lot but may be not learning the right things, more like ‘we have to do it this way now because we are that busy.
The nurses had to be responsible for all types of work in the units as well as being the group leader due to absence of experienced nurses. They described that during the summer holidays a lot of the staff was new in a unit, and they had to share administrative and organizational duties for which they were not prepared. They said that they did not know much about organizing hospital work and were untrained in many procedures. This made the situations overwhelming; ..most of all I wanted to run off, just to escape, and after three months I went on sick leave. It is pretty tough to think about it, and to talk about it as well.
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Discussion As stated above, the purpose of this study was to highlight the experience of being newly educated nurses working in internal medicine and surgical units. The main results discussed are feelings of unpreparedness and surprised by responsibility. It is likely impossible to recognize and prepare for all the challenges nurses meet in their professional life. The narratives indicate that the newly educated nurses had a strong feeling of being unprepared and being cast out into a different reality. This implies a need for new work place introductory programs (Morrow, 2009). From the evidence presented, an organized transition program to the graduate nurse role seemed to be missing. Orientation programs are reported to be very useful for newly educated nurses (Cockerham et al., 2011). The nurses interviewed perceived their start as professional nurses in hospital units to have only minor links to the practical component in their education. They experienced that hospital practice and reality differed from what they learned (Maben et al., 2006). Their lived experiences and learning during their theoretical and practical education did not enable them to feel well-enough prepared for the professional job in hospital units. Problems connected to education-to-job transition are well known (Morrow, 2009; Boychuk Duchscher and Cowan, 2004; Thidemann, 2005; Bisholt, 2011). The nurses in this study had been taught to embrace the best ideals and practices of good nursing, namely: to care for patients implies being aware of patient’s physical, mental, social and spiritual character. Based on this, nursing care integrates both practical, relational and ethical attitudes and actions, including responsibility for the most weak and vulnerable among us (Martinsen, 2003). The newly educated nurses were looking forward to put into practice good nursing care, but found it very difficult to achieve this in the hospital setting. They were cast out like in a different reality in a practical field without a satisfying transition program to help them being professionals. Although nurses have to set priorities everyday, the newly educated nurses were not experienced and they needed to develop professional judgement to develop this skill. In the hospital, medical treatment had priority and good nursing care was often forfeited. The newly educated nurses found it frightening to be inexperienced in a hectic working situation. They reported a big difference between what they had developed as their professional identity during education, and what was demanded in hospital practice of them as professionals (Thidemann, 2005). This represents a gap between two different values in the same discipline (Skaug, 1994, Maben et al., 2006). They felt that the values acquired from nursing education represent ideals and knowledge about performing the best caring, while values in hospital care are primary based on curing and cost-effectiveness. This is in accordance with what is described by Havn and Vedi (1997) about the transition gap. In fact, nurses’ workplace in hospital care has two different cultures; the culture of service-oriented nursing, emphasizing nursing care with its different values, and then the bureaucratic, systemoriented culture that is task oriented, emphasizing cost effectiveness. According to Orvik (2002) it is possible to learn to be bicultural, but according to our study newly educated nurses are not prepared to do that. Thidemann (2005) found that nurses experienced a dilemma when the employeer had equal demands for care, efficiency and productivity. In our study it seems like nurses experience care, and quality of nursing care, to be less valued by the employers than efficiency and productivity. Still they were excited to learn a lot, but found that their working days were filled with new impressions and duties taking all their energy.
Nurses who recently have completed their education at the bachelor level constitute novices (Benner, 1984). Their professional behaviour reflects textbook knowledge, but they need guidance to handle different situations. Clinical practice is far too complex to learn from textbooks. Practical experience and dialogue about relevant approaches to developing good practical skills in clinical work are needed (Benner, 1984). The nurses’ narratives indicate that they experienced that stress and pressure dominated their working environment. The time required for reflection to promote professional development is difficult to find (Solli, 2009; Orvik, 2002). There were complicated work challenges with focus on medical work and efficiency, and often it was difficult to find supervision and support. This was a frustrating experience for the nurses. According to Solli (2009), two out of three nurses who start their professional career in hospital care quit after one year. Turnover leads to a relatively young staff of nurses, and this reduces the possibility of newly educated nurses learning from experienced nurses. In addition to the feeling of stress in general, the newly educated nurses had to handle situations with critically ill patients whose life was at stake, many of them approximately the same age as the nurses. This is not easy. There were touching situations that forced recognition of the reality of dying, even for young people. In the narratives the nurses expressed the weight of responsibility and stress they felt in such situations. To meet relatives is another difficult part of such demanding situations and the nurses felt too inexperienced to provide the best care and comfort. There might have been colleagues to ask for advices, but as professional nurses they felt that they had to handle it themselves. In addition, every human is unique and every such situation with its human to human relationship is unique. Working with people implies always meeting between unique individuals (Henriksen and Vetlesen, 2010). There is no recipe for handling this. The nurses have to go into it and the best way to handle it will follow from every unique situation. They feel that they are thrown into it, and have to stand it or to escape. To escape is impossible. To care for suffering and vulnerable people is an important part of good nursing care (Sørlie, 2001). The nurses’ narratives indicate that besides lack of experience, nurses experienced impossibility of performing this important part of professional caring. Maybe this is not all about their lack of experience in handling such situations, but just as much about their powerlessness in the situation, workload and a different value system. Our results show that the newly educated nurses ended up dissatisfied with a nursing role they did not foresee. They were quite unprepared for the role they were forced into, and had to legitimate themselves in different areas than they were educated to do. The consequences were that they compromised their conscience and their professional identity in order to meet the demands from working place and employer (Solvoll, 2007). Nursing care needs time, space and resources, and thus requires the recognition and support of the employers. Then newly educated nurses can develop professional competence and professional pride according to their professional identity (Sneltvedt and Sørlie, 2011). Experience cannot solve all such issues, but can help in accepting what is impossible to change (Sneltvedt and Sørlie, 2011). It is not possible to be prepared for every situation in life in general or in professional life. Nursing care concerns the most vulnerable parts of human life, and theoretical knowledge alone does not define the skills needed. Newly educated nurses need mentoring from experienced nurses, and time to acquire the practical knowledge and wisdom to carry out good nursing care. This implies challenges for both nursing education and employers regarding how to strengthen both education and transition to practice in order to the development of good nursing professionals.
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The overwhelming feeling of responsibility The narratives indicate that the newly educated possessed a strong sense of responsibility. The transition from student to professional was akin to facing a different reality; they realized they had to stand on their own feet from day one. Student preparation did not address fully what professional nursing responsibilities included, and they felt unprepared and somewhat shocked. Assuming responsibility is impossible to learn from books, it is a skill that needs practical education to get familiar with, and learn how to deal with. One has to know the field of responsibility and its implications. The nurses experienced that they had a lot to learn in a hectic atmosphere, but they were learning and developing themselves very quickly as they gained work experience. One can say it is nearly impossible to be prepared for the responsibility as long as one is inexperienced in the practical situation, and not skilled in the different tasks of care. It is the nursing role to accept and learn that responsibility is a big and important part of nursing, and they have to get supervision in assuming responsibility. This has to start early in the education programmes to get acquainted with and then increase during the education. The disparity between having competence at novice level, and the responsibility it implies to work as a professional nurse makes the nurses experience the responsibility as overwhelming (Benner, 1984). Responsibility is a key concept in ethics and moral practice (Sneltvedt et al., 2009). It is a key phenomenon in human relationships especially when patients are involved (Henriksen and Vetlesen, 2010). Løgstrup (1989) holds that responsibility means that one receives special demands. Responsibility demands a piece of work, an action, a decision or whatever it is, that shall be done not for one’s own case, but for the case of others, for whom we are responsible. Martinsen (2003) views nursing care as a moral practice. From this view nurses carry out a big moral responsibility in their professional work (LaSala, 2009). Their work consists of making decisions and acting on behalf of their patient’s welfare, taking care of suffering and vulnerability. The newly educated nurses have a general education in nursing but they are too inexperienced to be familiar with all situations. However, there are concurrent demands of being efficient while being professionals and responsible for the patients. Our results show that this situation might make the responsibility frightening and burdensome for the newly educated nurses. Their colleagues might be helpful, give advice and help, but no one can take away responsibility from a given individual (Sørlie, 2001). Sickness is one of the most vulnerable situations in life. The responsibility cannot be avoided by referring to regulating conditions imposed by working life (Løgstrup, 1989; Henriksen and Vetlesen, 2010; Sneltvedt et al., 2009). Nurses are responsible for providing patients with quality care. Their professional ethical standards are based on meeting with other human beings who need them. This is experienced as stress, and the nurses feel inadequate to carry out duties they are responsible for in a proper manner (Henriksen and Vetlesen, 2010). They feel that they are in an unsatisfactory nursing role that conflicts with a nurse’s professional identity. Their own professional identity might gradually change and lead to changed comprehension of nurses’ responsibility. The traditional nursing role, implying good nursing care, might be at stake. Our results indicate that newly educated nurses have to assume a lot of responsibility to keep the unit going. During holiday season, lack of personnel, many newly graduated and many nurses who are unfamiliar with the hospital unit, they find that responsibility to run the unit is difficult. The only person with an idea of the whole situation is the newly educated nurse. This seems to be too heavy a responsibility. To be professional includes influencing policies
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governing both nursing care and own working conditions (Orvik, 2002). Novice nurses do not have that level of professional skill to influence this (Benner, 1984). Solli found a high degree of disparity between the demands nurses meet when they first start their career and how long it takes before they, in fact, have developed real competence to master such demands (Solli, 2009). As an example, developing skills to be a leader and administer nursing practice takes around three years. The employers, however, expect this competence to be present when the newly educated nurses start to work. The workload has to be adjusted to the competence level nurses have during the first years after their graduation, until they have the experience needed to develop adequate competence. Many newly educated nurses meet such a demanding workday. It makes some of them leave their profession before they have reached the competence level they could be able to achieve (Solli, 2009). Many international studies of this topic focus on the problematic transition from student to professional, similar to our study. Different models are developed to meet the problem with good strategies. The question is if there is enough focus on the postgraduate situation. A model might be developed to make students prepared for the transition during their education. Conclusions Newly educated nurses employed in hospital units experienced a different reality in relation to learned values and responsibilities. They felt unprepared and overwhelmed when asked to multi-task, with efficiency as a priority, as well having to assume major responsibilities. An ‘easing-in strategy’ is recommended. It is, however, impossible to recognize and prepare for all the challenges nurses meet in their professional life. Unpreparedness as an existential phenomenon has to be considered as part of professional life. More research has to be carried out with focus on preparedness for practice. Both educational institutions and employers must develop programs to give newly educated nurses a meaningful start to their professional life, to develop professional skills and encourage stable and skilled performers of nursing care. Acknowledgements The hospital leadership and the informants are hereby acknowledged for their participation. References Alsvåg, H., 2006. Nursing education in light of new RNS’ professional experiences. Nurs. Sci. Res. Nordic Ctries. 22, 34e38. Benner, P., 1984. From Novice to Expert e Excellence and Power in Clinical Nursing Practice. Addison-Wesley Publishing Company, Health Sciences Division, Menlo Park, California, USA. Bisholt, B.K.M., 2011. The professional socialization of recently graduated nurses e experiences of an introduction program. Nurse Educ. Today. http://dx.doi.org/ 10.2016/j.nedt.2011.04.001. Boychuk Duchscher, J.E., Cowan, L.S., 2004. The experience of marginalization in new nursing graduates. J. Psychiat. Ment. Health Nurs. 12, 387e395. Chang, E., Hancock, K., 2003. Role stress and role ambiguity in new nursing graduates in Australia. Nurs. Health Sci. 5, 155e163. Cockerham, J., Figueroa-Altmann, A., Eyster, B., Ross, C., Salamy, J., 2011. Supporting newly hired nurses: a program to increase knowledge and confidence while fostering relationships among the team. Nurs. Forum 46, 231e236. Havn, V., Vedi, C., 1997. In Deep Water e Recently Graduate Nurse’s Competence in Somatic Ward. SINTEF-IFIM, Trondheim, Norway. Henriksen, J.O., Vetlesen, A.J., 2010. Closeness and Distance (Nor). Gyldendal Akademisk, Oslo. Kramer, M., 1974. Reality Shock; Why Nurses Leave Nursing. CV Mosby, Saint Louis, Mo. LaSala, C.A., 2009. Moral accountability and integrity in nursing practice. Nurs. Clin. N. Am. 44, 423e434.
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