Role Transitions

Transitions are passages or changes from one situation, condition, or state to another that occur over time. They have been classified into the following four major types: developmental (e.g., becoming a parent, midlife crisis), situational (e.g., graduating from a nursing program, career change, divorce), health or illness (e.g., dealing with a chronic illness), and organizational (e.g., change in leadership, new staffing patterns) (Schumacher & Meleis, 1994).

Another factor in the transition process is the new level of knowledge and skill required, as well as the availability of needed resources within the environment. Dealing with new knowledge and skills can be challenging and stressful and can lead to a variety of different emotions related to the expectation of the new graduate to be competent (Box 1.1). This will resolve as your confidence grows and you have more understanding of the concept of how to “think like a nurse.”

Transitions are a part of life and certainly a part of nursing. Although the following discussions on role transition and reality shock focus on the graduate nurse experience, there are many applicable points for the new student as well. As you learn more about transitions, reality shock, and the graduate nurse experience, think about how this information may also apply to your transition experience into and through nursing school (Critical Thinking Box 1.1).

Looking back, what transitions have you experienced? What transitions are occurring in your life now? Has your entry into, as well as progress through, nursing school caused transitions in your personal life? Has your anticipated job search caused transitions in your professional as well as personal life?

Health care organizations are very concerned about your transition experience and job satisfaction during that first 6 months of employment. Have you been hearing about “evidence-based practice?” Well, it is working for you now! During the first 6 months of employment, new graduates need a period of time to develop their skills in a supportive environment. Employee retention and job satisfaction are key issues with hospitals; confidence in performing skills and procedures, nurse residency programs, and dependence versus independence are key graduate nurse issues driving this research. The well-being of the graduate nurse and the ability to deliver quality nursing care during the transition period have sparked research to validate the need for special considerations of the graduate nurse experiencing transition (Casey et al., 2004; Duchscher, 2008, 2009; Godinez et al., 1999; Lavoie-Tremblay et al., 2002; Spector et al., 2015a; Steinmiller et al., 2003; Varner & Leeds, 2012). With identification of the basic problems encountered by new graduates during this first 6 months, there is a concerted effort to begin to meet the special needs of graduate nurses and assist them to “think like a nurse” (Research for Best Practice Box 1.1). Thinking like a nurse involves critical thinking, decision making, and clinical judgment. You may think these terms mean the same thing, but they do not. Just what exactly do these terms mean?

The role transition process that occurs on entry into nursing school and the process from student to graduate nurse do not take place automatically. Having the optimal experience during role transition requires a great deal of attention, planning, and determination on your part. How you perceive and handle the transition will determine how well you progress through the process. It is important that you keep a positive attitude. The challenges and rewards of clinicals, tests, and work situations will cause your emotions to go up and down, but that is okay. It is expected, and you will be able to deal with it effectively. It is important that you keep a positive attitude. The wide range of emotions experienced during the transition process can often affect your emotional and physical well-being; check out the discussion of self-care strategies in Chapter 2.

So, let’s get started. Reality shock is often one of the first hurdles of transition to conquer in your new role as a graduate nurse or registered nurse (RN or Real Nurse).

The recent graduate in the workplace is expected to be a capable, competent nurse. That sounds fine. However, sometimes there is a hidden expectation that graduate nurses should function as though they have 5 years of nursing experience. Time management skills, along with the increasing acuity level of patients, are common problems for new graduates. This situation may leave you with feelings of powerlessness, depression, and insecurity because of an apparent lack of effectiveness in the work environment. There are positive ways to deal with the problems. You are not alone! Reality shock is not unique to nursing. It is present in many professions as graduates move from the world of ­academia to the world of work and begin to adjust to the expectations and values of the workforce.

Kramer (1974) described the phases of reality shock as they apply to nursing (Table 1.1). Although she identified this process in 1974, these phases remain the basis for understanding the implications of reality shock and successfully progressing through the process. In our current world of nursing, we are still dealing with this same process. Adjustments begin to take place as the graduate nurse adapts to the reality of the practice of nursing. The first phase of adjustment is the honeymoon phase (Fig. 1.1). Recent graduates are thrilled with completing school and accepting a first job. Life is a “bed of roses” because everyone knows nursing school is much harder than nursing practice. There are no more concept care maps to create, no more nursing care plans to write, and no more burning the midnight oil for the next day’s examination. No one is watching over your shoulder while you insert a catheter or administer an intravenous medication. You are not a “student” anymore; now you are a nurse! During this exciting phase, your perception of the situation may feel unreal and distorted, and you may not be able to understand the overall picture.

The honeymoon phase is frequently short lived as the graduate begins to identify the conflicts between the way she or he was taught and the reality of what is done. Every graduate nurse has a unique way of coping with the situations; however, some common responses have been identified. The graduate may cope with this conflict by withdrawing or rejecting the values learned during nursing school. This may mark the end of the honeymoon phase of transition. The phrase “going native” was used by Kramer and Schmalenberg (1977) to describe recent graduates as they begin to cope and identify with the reality of the situation by rejecting the values from nursing school and beginning to function as everyone else does.

Kramer (1974) described four groups of graduate nurses and the steps they took to resolve reality shock. The graduates who were considered to be most successful at adaptation were those who “made a lot of waves” within both their job setting and their professional organizations. Accordingly, they were not content with the present state of nursing but worked to effect a better system. This group of graduates was able to take worthwhile values learned during school and integrate them into the work setting. Often, they returned to school—but not too quickly. Since Kramer’s original work, students are now encouraged to go back to school fairly quickly, especially with the emphasis from the Institute of Medicine (IOM) report of encouraging more advanced degrees in nursing.

The job expectations of the hospital administration or the employing community agency and the educational preparation of the graduate nurse are not always the same. This discrepancy is considered to be the basis of reality shock. Relationships among the staff, nursing professionalism, job satisfaction, and employee alienation were studied by Casey and colleagues (2004), Roche and colleagues (2004), and Varner and Leeds (2012). Interestingly, the issues of reality shock and role transition described by Kramer in the early 1970s are still around. We (nurses) have entered the 21st century with many of the same issues we had in the 20th century.

It might seem to you right now, after reading all of this information, that reality shock is a life-threatening situation. Be assured, it is not. However, you may experience some physical and psychological symptoms in varying degrees of intensity. For example, you may feel stressed out or have headaches, insomnia, gastrointestinal upset, or a bout of post-student blues. Just remember that it takes time to adjust to a new routine and that sometimes, even after you have gotten used to it, you still may feel overwhelmed, confused, or anxious. The good news is that there are various ways to get through this critical phase of your career while establishing a firm foundation for future professional growth and career mobility. Try the assessment exercise in Critical Thinking Box 1.2 and review the clinical judgment case scenario in the NGN Box 1.1.

More recently, based on research by Duchscher (2008) building on Kramer’s seminal work, the process has been redefined as transition shock to describe the transition experience within a contemporary health care environment and according to Wakefield (2018), “penetrates beyond professional aspects of shock” (p. 47). Duchscher and Windey (2018) identify the stages of transition as a process of “becoming” that occur within the initial 12 months of nursing practice of the new graduate nurse and involves three stages: doing, being, and knowing. Box 1.2 summarizes the three stages.

Does the transition begin at graduation? No. It started when you began to move into the novice role while in your first nursing course (Table 1.2). According to Benner (2001; 1984, p. 20):

Beginners have no experience of the situation in which they are expected to perform. To get them into these situations and allow them to gain experience also necessary for skill development, they are taught about the situation in terms of objective attributes, such as weight, intake/output, temperature, blood pressure, pulse, and other objective, measurable parameters of a patient’s conditions—features of the task world that can be recognized without situational experience.

For example, the instructor gives a novice or student nurse specific directions on how to listen for bowel sounds. There are specific rules on how to guide their actions—rules that are very limited and fairly inflexible. Remember your first clinical nursing experiences? Your nursing instructor was your shadow for patient care. As nursing students enter a clinical area as novices, they have little understanding of the meaning and application of recently learned textbook terms and concepts. Students are not the only novices; any nurse may assume the novice role on entering a clinical setting in which he or she is not comfortable functioning or has no practical experience. Consider an experienced medical-surgical nurse who floats to the postpartum unit; he or she would be a little uncomfortable in that clinical setting.

By graduation, most nursing students are at the level of advanced beginner. According to Benner (2001; 1984, p. 20):

Advanced beginners are ones who can demonstrate marginally accepted performance, ones who have coped with enough real situations to note (or to have pointed out to them by a mentor) the recurring meaningful situation components….

To be able to recognize characteristics that can be identified only through experience is the signifying trait of the advanced beginner. Thus, when directed to perform the procedure of checking bowel sounds, the students at this level are learning how to discriminate bowel sounds and understand their meaning. They do not need to be told specifically how to perform the procedure.

Let’s look at what you and your nursing instructors can do to promote your well-being and success during the role-transition experience. These activities reinforce your progress and movement along the continuum from advanced-beginner to competent nurse (see Table 1.2).