Transition from graduate registered nurses in the practice of the registered nurse

There are many issues associated with the transition from graduate registered nurse into practicing registered nurse. Recent studies have found the phase to be a stressful period for many graduates the main challenges were fitting into social groups, delegation, hostility and patient-centred care (Rush et al, 2013); (Feng & Tsai 2012). However, research has shown that with appropriate education, guidance and support the transition can create better staff and patient satisfaction, resulting in lower turnover rates (Orsini, 2005). This research highlights the need to develop appropriate pathways and evidence-based management for new graduate nurses.

This essay will endeavour to outline the evidence-based practice for the management of patient-centred care and hostility in the workforce, in conjunction with the transitioning to registered nurse phase. It will be centralised around class discussion forums and how they impacted personally (Appendix 2A, 2B, 2C) in order to applicably manage future situations. Patient-centred care is a fundamental issue which was discussed at great length during one of the forums (Appendix 2A).

It seemed most students had their own opinion already formed about patient-centred care and in turn their own experiences. It was a topic which I felt needed further understanding due to a lack of consistency with student viewpoints and due to it being an ill managed issue within healthcare services.

A recent study examining the barriers to overcome patient-centred care found that 64% of nurses were aware of deficits in standards of care, but felt they did not have enough time to perform vital nursing tasks such as addressing patient’s concerns and providing relevant information to both the patient and their family (West, Barron, & Reeves, 2005).

Furthermore, nurses reported that a lack of staff, space and equipment were also to blame (West, Barron, & Reeves, 2005). Kvale & Bondevik, (2008) state that patient-centred care is a term which is globally used yet it is difficult to define, resulting in challenges in implementing appropriate interventions. This may be a result of patients differing satisfactions and expectations such as personal beliefs, ideas and opinions which are individual (Okougha, 2013). Research suggests that graduate registered nurses require guidance and education in order to gain confidence and empowerment (Glynn & Silva, 2013). A recent study found that when education was provided to nurses in relation to current patient-centred care and how to improve it, 90% of nurses positively changed their behaviour to increase patient satisfaction (Okougha, 2013). As a graduate registered nurse I need to have a profound and comprehensive understanding about patient-centred care and how to implement it in order to provide safe and effective management to all my patients. According to Cronin, (2004) patient-centred care is recognising each patient as an individual; building therapeutic relationships including with family and friends; and involving a multidisciplinary team.

This in turn provides differing perspectives on the issue. The World Health Organisation uses the word ‘responsiveness’ in regards to patient centred care and states “recognising responsiveness is an intrinsic goal of the health care system and reinforces that the health care systems are there to serve the people” (World Health Organisation, 2000). A recent qualitative study examined patient’s perspectives in relation to patient-centred care (Griffiths et al, 2012). It found that although patients were different and required diverse needs, they also shared many similarities such as requiring empathy, listening, communication and non-judgemental patient-centred care (Griffiths et al, 2012). There was also concern if current education can develop a nurse’s preparedness in delivering quality care (Griffiths et al, 2012). One of the participants stated “you might be the best clinician in the world but if you can’t communicate and you can’t listen properly to people and you don’t take on board and understand what they’re saying you may as well go dig the street” (Griffiths et al, 2012).

Furthermore another participant stated “…each individual should be [evaluated] and their needs be assessed and implemented on that particular individual…I just feel it’s a conveyor belt system. Get them in and get them out sort of thing” (Griffiths et al, 2012). In another qualitative review which explored nurse’s perspectives on patient-centred care, suggested time management was the largest barrier preventing them from communicating effectively with their patients (Chan et al, 2012). One nurse stated “sometimes, I have to deal with 20 patients in one single shift… if one needs 10 minutes and there are 20 patients in total, how much time would we have to spend on this? Don’t we need to do other tasks?” (Chan et al, 2012). According to the Australian Commission on safety and quality in health care, (2011) effective patient-centred care is employed through training health professionals to communicate simple information such as pharmaceutical knowledge and provide educational material which increases a patient’s self-assurance and understanding. Additionally, initiating patient surveys is an effective tool in order to determine the most appropriate interventions (Australian Commission on safety and quality in health care, 2011). Current research has found that better patient satisfaction and patient-centred care, results in a decreased length of stay; reduces readmission; decreases rates of hospital acquired infections; and improves preventative services (Boulding et al, 2011); (Flach et al, 2004). It is therefore imperative that all graduate nurses have an understanding about patient-centred care and successfully implement appropriate interventions. Patient-centred care has encouraged me to re-think how I view and treat my patients. Current literature has highlighted the importance that patient-centred care plays in delivering quality and safe care as a graduate registered nurse. In respect to Appendix 1, the toolkit and strategies developed from the discussion forums have provided me with a clearer understanding in how to manage effective patient-centred care. The strategies developed are simple and easy to follow and include recognising each patient as an individual; and focus on communication to build a therapeutic relationship.

I now understand the importance of having a structured support network within the workplace in order to maintain regular support and direction. In future practice as a graduate registered nurse I will endeavour to find an appropriate mentor which will provide insightful knowledge and realistic expectations. As stated in Appendix 2A I now recognise it is necessary to have an understanding about patient centred care in order to successfully manage a patient’s individual needs. Without knowledge within this area a nurse is unable to properly care for their patients. Hostility in the workforce was another topic which swayed my attention during the discussion forums (Appendix 2B). It was an issue which I had not considered to be a problem once becoming a registered nurse and working within a professional group. However, as the class discussed their own personal experiences in regards to being a student and coming across hostility, I too remembered that nurses are often intimidating and unapproachable during clinical placements. This issue is important as research has suggested graduate registered nurses demonstrate vulnerability which can easily lead to bulling or hostility in the workforce (Hickson, 2013). Hostility in the workforce has been viewed as a rite of passage, suggesting new graduates need to experience the language, culture and rules of the workforce (Hickson, 2013). In a study conducted by McKenna et al, (2003) it found many new graduates experienced some form of hostility but due to fear they did not report the occurrence.

The study also highlighted that new graduates felt resentment in the form of interpersonal conflicts; blocked learning; emotional neglect; feeling undervalued; lack of supervision; threat of rumours or lies being spread in response to speaking out (McKenna et al, 2003). In another recent study it found that 46% of the nurses identified hostility in the workforce as serious or somewhat serious (Stanley et al, 2007). It also discovered that 65% of the nurses had observed hostile behaviours by fellow co-workers (Stanley et al, 2007). Furthermore, Simon, (2008) revealed that 48% of nurses that were less than five years in a unit were the most frequently bullied. Additionally, 31% of new graduates reported they were bullied significantly generating intent to leave (Simon, 2008). In respect to Appendix 2B, this issue is vitally important to me as I have seen first-hand how hostility in the nursing environment can occur. I can appreciate that as new graduates we need guidance and support during such a vulnerable transition. I furthermore recognise how hostility and bullying can impact on a nurse’s performance, job satisfaction and patient safety. It is therefore imperative that I have an understanding about appropriate strategies for resolving these issues. According to the American Nurses Association, (2012) any form of abuse against nurses is a violation of inherent worth, dignity and human rights. Also that abusive behaviour by a nurse is viewed as violence against the nursing code of ethics (American Nurses Association, 2012). Growe, (2013) suggests hostility can also be described as bullying, lateral violence, horizontal violence and disruptive behaviour. Additionally, it is behaviour that is persistent and ongoing; unwanted comments or actions affecting a person’s dignity, and overt and covert actions which threaten the performance of a health care worker (Growe, 2013). A study conducted by Kelly and Ahern, (2009) reviewed the perspectives of new graduates in Australia.

They discovered there were three key themes which prevented a successful socialisation process (Kelly & Ahern, 2009). They included language barriers, which required the nurses learn the culture of the language; ‘eating their young’ or power games and unpreparedness (Kelly & Ahern, 2009). One graduate nurse stated “I think that a lot of RN’s out there are on a power trip and think that the best way to teach students is by humiliating them and putting them down as much as possible and saying, surely you know that” (Kelly & Ahern, 2009). Another graduate stated “The sharpness of some of the staff, the way some of them speak to you has become an increasing burden” (Kelly & Ahern, 2009). In another recent qualitative study, it reviewed registered nurses’ perspectives in regards to graduate nurses (Baumberger-Henry, 2012). It found two themes which involved lacking confidence and fitting in with the units culture (Baumberger-Henry, 2012). One nurse stated “…not knowing what to do and having to request assistance is perceived as a weakness that contrasts the need to feel independent…keeps the advanced beginner from asking questions, creating a catch 22 situation…other nurses view new graduates as weak and burdensome” (Baumberger-Henry, 2012). Another participant stated “some nurses turn their backs when new graduates ask a question…sometimes new graduates don’t make it just because of other personalities…” (Baumberger-Henry, 2012).

It is clear from the evidence that hostility in the workforce is a widespread issue. Furthermore, it can be seen that graduate registered nurses are the ones most at risk and burdened with this problem. It is therefore necessary that all nurses have an appropriate understanding about how to deal with these situations effectively in order to create job satisfaction. According to Vessey et al, (2012), workplace hostility can be decreased by involving the whole nursing team, providing information on what is good and bad practice, and making the staff more aware of the issue. Hostility in the workforce has made me apprehensive about starting out as a new graduate in the health care setting. However, from current literature I feel more confident in recognising signs of hostility or bullying, and feel capable in addressing the problem with either my mentor, or if applicable, senior staff. From the toolkit in Appendix 1, the strategies were developed for graduate nurses like myself. They suggested simple strategies which may help prevent other nurses from becoming annoyed and frustrated with new graduates. The strategies include using a communication tool such as ‘SBAR’ in order to appropriately address what needs to be done; not to take conflicts personally; know your own scope of practice in order to maintain safe and competent work; skill up to gain additional knowledge and experience; and know your professional boundaries. From the current literature and toolkit strategies I now have a deeper understanding about the impacts of workplace bullying and how it affects graduate nurse’s performance and job satisfaction. By having a clearer understanding about the issue I feel confident in being able to apply these strategies when challenged with a similar circumstance.

This essay has reviewed the evidence-based practice for the management of patient centred care and hostility in the workforce. It was conducted in conjunction with the transitioning to registered nurse phase. By examining current literature and differing perspectives on these issues, a clearer understanding about their impacts and managements strategies have been developed. It is important that all nurses have an adequate understanding about patient centred care and hostility in the workforce given their impacts on quality patient management and safety. The toolkit in Appendix 1 has provided insightful strategies in order to help graduates deal with these situations once within the workforce. In regards to Appendix 2A and 2B, these topics have provided me with a deeper understanding about expectations as a graduate registered nurse. Additionally, they have allowed me to gain insight and preparedness in relation to entering the workforce. It is evident that having a clear understanding about both issues is vital in order to be successful within nursing in future industries.

American Nurses Association. (2012). Combating Disruptive Behaviours: Strategies to promote a healthy work environment. Retrieved 22/5/2013 from: Australian Commission on safety and quality in health care. (2011). Patient centred care: improving quality and safety through partnerships with patients and concurmers. ACSOQHC, Sydney. Retrieved 24/5/2013 from: Baumberger-Henry, M. (2012). Registered nurses’ perspectives on the new graduate working in the emgerncy department or critical care unit. Journal of Continuing Education in Nursing, 43(7), 299-305.doi:10.3928/00220124-20111115-02 Boulding, W., Glickman, S., Manary, M., Shulman, K., Staelin, R. (2011). Relationship between patient satisfaction with in patient care and hospital readmission within 30 days. American Journal of Managed Care, 17(1), 41-48 Chan, E., Jones, A., Fung, S., & Wu, S. (2012). Nurses perception of time availability in patient communication in Hong Kong. Journal of Clinical Nursing, 21(7), 1168-1177. Doi: 10.1111/j.1365-2702.2011.03841.x Cronin, C. (2004). Patient Centred Care-An overview of Definitions and Concepts. Washington DC: National Health council Feng, R., & Tsai, Y. (2012). Socialisation of new graduate nurses to practising nurses. Journal of Clinical Nursing, 21(13), 2064-2074. Doi:10.1111/j.1365-2702.2011.03992.x Flach, S., McCoy, K., Vaughn, T., Ward, M., Boots-Miler, B., Doebeling, B. (2004). Does Patient centred care improve provision of preventative services? Journal of General Internal Medicine, 19(10), 1019-1026 Glynn, P., & Silva, S. (2013). Meeting the needs of New Graduates in the Emergency Department: A qualitative study evaluating a new graduate internship program.

Journal of Emergency Nursing, 39(2), 173-178. Doi:10.1016/j.jen.2011.10.007 Griffiths, J., Speed, S., Horne, M., & Keeley, P. (2012). A caring professioinal attitude: What service users and carer seek in graduate nurses and the challenge for educators. Nurse Education Today, 32(2), 121-127. Doi: 10.1016/j.nedt.2011.06.005 Growe, S. (2013). Bullying/Lateral Violence/ Horizontal Violence/ Distruptive Behavior in the workplace. Nevada Rnformation, 22(1), 6 Henderson S. Power imbalance between nurses and patients: a potential inhibitor of partnership in care. Journal of Clinical Nursing 2003,12(4), 501–8. Hickson, J. (2013). New Nurses’ perceptions of hositilty and job satisfaction: magnet versus non-magnet. The Journal of Nursing Administration, 43(5), doi:10.1097/NNA.0b013e31828eebc9 Kelly, J. & Ahern, K. (2009). Preparing nurses for practice: A phenomenological study of the new graduate in Australia. Journal of Clinical Nursing, 18(6), 910-918. Doi:10.1111/j.1365-2702.2008.02308.x Kvale, K., & Bondevik, M. (2008). What is important for patient centred care?

A qualitative study about the perceptions of patients with cancer. Scandinavian Journal of Caring Sciences, 22(4), 582-589. Doi:10.1111/j.1471-6712.2007.00579.x McKenna, B., Smith, N., Poole, S., Coverdale, J. (2003). Horizontal violence:experiences of registered nurses in their first year of practice. Journal of Advanced Nursing, 42(1), 90-96 Okougha, M. (2013). Promoting patient centred care through staff development. Nursing Standard, 27(34), 42-46 Orsini, C. (2005). A nurse transition program for orthopaedics: creating a new culture for nurturing graduate nurses. Orthopaedic Nursing/ National Association of Orthopaedic Nurses, 24(4), 240-246 Rush, K., Adamack, M., Gordon, J., Lilly, M., & Janke, R. (2013).

Best practices of formal new graduate nurse transition programs: an integrative review. International Journal of Nursing Studies, 50(3), 345-356. Doi: 10.1016/j.ijnurstu.2012.06.009 Simon, S. (2008). Workplace Bullying experienced by Massachusetts registered nurses and the relationship to intention to leave the organisation. Advance Nursing Science. 31(2), 48-59 Stanley, K., Martin, M., Michel, Y., Welton, J., Nemeth, L. (2007). Examing lateral violence in the nursing workfoce. Issues Mental Health Nursing. 28(11), 1247-1265 Vessey, J., Demarco, R., Gaffney, D., & Budin, W. (2009). Bullying of staff registered nurses in the workplace: a preliminary study for developing personal and organisation strategies for the transformation of hostile to a healthy eorkplace environments. Journal of Professional Nursing:Offical Journal Of The American Association Of Colleges Of Nursing, 25(5), 299-306. Doi:10.1016/j.profnurs.2009.01.022 West, E., Barron, D., & Reeves, R. (2005). Overcoming the barriers to patient-centred care: time, tools and training. Journal of Clinical Nursing, 14(4), 435-443. Doi:10.1111/j.1365-2702.2004.01091.x World Health Organisation. (2000). The World Health Report 2000- Health System: Improving Performance. Geneva, World Health Organisation, 1-215

Appendix 1
Discussion Forum 1 – Learning and Teaching being a teacher and a learner in a health care environment 1. List strategies that can reassure a graduate registered nurse that a patient’s learning needs are met

| Strategy | Rationale|
1.| Build rapport.| This reduces fear and anxiety, allowing patients to ask more questions and be involved in their own treatment.| 2.| Get them to repeat what you say in their own words.| This reassures they have understood what you have explained.| 3.| Write important information down and/or provide educational material.| This allows patients to reflect on information in their own time.| 4.| Ask the patient what the need clarifying.| Some patient may withdraw from asking simple questions as nurses appear too busy. | 5.| | |

2. List strategies that will ensure that a graduate registered nurse can be a lifelong learner in a health care setting

| Strategy | Rationale|
1.| Communicate clearly| To improve interprofessional communication; increases trust and respect. | 2.| Recognise each patient as an individual with their own needs| To develop quality patient centered care.| 3.| Focus on patient centered communication to build therapeutic relationships| This help improve effective patient centered care and provides and safe and quality nursing.| 4.| Create a career vision| Provides a pathway in which goals can then be developed and attained.| 5.| Develop a professional portfolio| Provides a reference point to store and sort important information and documents.|

Discussion Forum 2 Workforce issues and challenges
1. List strategies that will ensure that a graduate registered nurses are effective team members

| Strategy | Rationale|
1.| Participate in further education| Shows enthusiasm and provides further knowledge.| 2.| Seek critical feedback from senior staff| Outlines how one is perceived and thus they will have a deeper understanding about themselves.| 3.| Always use professional and polite language. | Encourages rapport and friendliness within the staff| 4.| | |

5.| | |

2. List strategies that a graduate registered nurse can use to reduce their theory practice gap. Give a GRN specific rationale to support each strategy

| Strategy | Rationale|
1.| Establish a bond with a mentor or preceptor.| As a GRN this will provide support and guidance in order to applicable use theory in practice.| 2.| Develop effective communication skills.| This establishes rapport with patients and other colleagues. | 3.| Write reflections.| Allows GRN to identify their strengths and weakness | 4.| Skill up where possible| This provide GRN with further knowledge and understand in a particular field| 5.| | |

Discussion Forum 3 Workplace issues and challenges
1. List strategies that will empower a graduate registered nurse to work effectively in a hostile and aggressive environment

| Strategy | Rationale|
1.| Assertive communication| By using communication tools and assertive language, GRN can effectively explain what it is they need in a professional manner. | 2.| Scope of practice| It’s important to know one’s own scope of practice in order to provide safe and quality nursing care.| 3.| Professional Boundaries| Important in order to not cross any professional
boundaries, impacting on employment status.| 4.| Know where to report in your health facility| Many healthcare setting have their own way of reporting workplace violence, so it’s important to know how to manage the situation. | 5.| Mediate – “in house”| this is generally the first step, talking to the NUM, in order to try to resolve the issue before it get too out of control|

2. List strategies that a graduate registered nurse can use to delegate tasks effectively

| Strategy | Rationale|
1.| Delegate to the right person| Important to know their competencies and qualifications, this can be achieved simply by asking.| 2.| Make sure timing is right| Be sure not to delegate to a person who appears very busy as this can cause conflicts and also poor management.| 3.| Use appropriate positive words| Provide the reason why you need the help and why you cannot complete it, in order for the other person to fully understand. | 4.| Never redo delegated tasks| As this will diminish authority and allow other nurses to ‘walk over’ you. | 5.| | |

Discussion Forum 4 Ethical and Legal Issues and Challenges 1. List strategies that will empower a graduate registered nurse to transition effectively to their new roles and responsibilities | Strategy | Rationale|

1.| Find a mentor.| Provides necessary leadership, support and guidance.| 2.| Develop good organisational skills.| This increase time management and maintains patient safety.| 3.| Never be afraid to ask questions| This increases knowledge and understanding and thus decreases adverse events.| 4.| Understand yourself and limitations.| Helps to identify what learning pathways may need to be further established.| 5.| | |

2. List strategies that a graduate registered nurse can use to advocate for best practice policies to be followed

| Strategy | Rationale|
1.| Know when to partake in mandatory reporting| Important in order to provide safe nursing practice.| 2.| Know who to talk to if a problem arises in the workforce| Provides a support network. | 3.| Seek advice from regulatory councils| Provides further knowledge and guidance into a situation in regards to the law. | 4.| Collaborate as an interdisciplinary team| This provides safe and effective care to all patients. | 5.| | |

Appendix 2A
Reflection: Patient-Centred Care
During the discussion forums in my tutorial class, patient-centred care was one of the topics which grasped my attention. The forum provided an insight into what is involved in patient-centred and examined some effective strategies. I found this topic interesting as the class shared their experiences and viewpoints on the issue. One participant shared that when recently working in aged care as an assistant nurse, patient care was often carried out in regards to time restraints and thus resulting in patients being rushed through their daily cares and/or being woken up very early to accommodate nursing staff. I found this very worrying as I don’t believe that the described experience is appropriate patient-centred care and therefore these aged care patients are not being effectively cared for. However, it also made me wonder where else in the clinical setting is patient-centred care being ill-managed? The discussion forum outlined that patient centred care is providing adequate cares, gathering appropriate information, respecting values, educating the patient, involving their family and friends and providing emotional support. Also, without knowledge within this area, a nurse is unable to successfully care and manage their patients. It is important to have an understanding about patient centred care in nursing as effectively that’s what nurses should be advocating. Patient centred-care is individual and requires building a therapeutic relationship to allow the patient be actively involved. Additionally, patient-centred care is vital role in providing safe and appropriate treatment to all patients. This forum topic has provided me with a deeper understanding about the importance patient centred care in order to be a

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