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Nurse Managers Career Planning
Nurse Managers have demanding and complex responsibilities that involve coordinating work of individuals with varying education, skills, and personalities of providing safe, high quality patient care. The Nurse managers are accountable for staff performance, resource utilization, financial management, and patient outcomes. The Nurse Managers also ensure that patient care is delivered in line with the standards of practice and organizational ethics and policies. According to Anonson et al., (2014), good nurse managers provide leadership and ensures that his/her department runs smoothly.
After evaluating myself with the skills inventory, I found that I have the various strengths and weakness in the following areas;
Personal and Professional Accountability
First, I noted that I am competent enough when it comes to personal growth and development. This is because I hold a Bachelors OF Science Nursing (BSN) degree which has equipped me to meet the demands weighed on today’s nurse. With this degree, I have acquired skills in critical thinking, case management, and health promotion in order to practice across various inpatient and outpatient settings. I also possess leadership skills that are crucial for anyone that would like to serve as a nurse manager. In my practice, I adhere to the expected nursing codes of ethics.
However, I am a novice when am required to make appropriate decisions surrounding the several ethical dilemmas in my practice. For instance, a teen who had been diagnosed with syphilis due to unprotected sex asked me to lie to her mum about her condition. Moreover, I am also an active member of several nursing associations such as the American Nursing Association (ANA); an important institution that safeguards our welfare as nurses.
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Career Planning
I am an expert in this area because I understand my role as a BSN nurse and what is expected of me. I also intend to pursue a master’s degree in Nursing. However, I have not yet decided on the program I need to pursue.
Personal Journey Disciplines
I noted that I am an expert in this area. I have vital management skills that can aid me in educating and supervising staff without micromanaging. I can use conflict resolution and negotiation skills to enhance collaboration between physician, staff, and clinical leaders. I can also mentor and coach stuff at all levels. Moreover, I am flexible hence I can adapt quickly in the field of healthcare as patients usually develop problems. However, I find it a bit challenging to make agent decisions of care on my own in accordance to the changing needs. I prefer consulting someone else before I can implement a decision.
Reflective practice reference behaviors/tenets
After rating myself on this area, I found that I uphold integrity and transparency in all my dealings. I also have the desire of developing my potential. For instance, I usually challenge myself to attain the standards that some of my predecessors in the field of nursing have set. This aids me to discover my potential, know my weaknesses and strengths whenever I want to attain certain goals.
However, I do not know how to create and maintain a balance that renews and regenerates my spirit and body so that I can grow continually. This is because I usually find myself being caught up in the profession, squeezing some personal time relax and rejuvenate has always been a challenge to me risking work burn out.
Reflective practice is one of the most important pillars in my career. It aids my making sense of human frailties such as mental and physical health and the dynamics between the relationship between human beings and the system in which they function.
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Often, leaders are charged with the responsibility of creating change processes in an organization (Schaffer et al., 2013). Change processes that involve upgrade of tools and techniques, human resources, and basic rules and controls within a hospital are the mandate of managers within the organization. With my leadership set, I will be able to make the change initiatives real and tangible rather than abstract.
I will also ensure that I awaken the enthusiasm and ownership of the proposed change within the organization. My leadership set also helps me to be accountable for filling the gap between strategic decisions and the certainty of executing the change within the workforce and structure of the institution. I will use my communication skills to ensure that the staff is updated on all change activities that are taking place and what we expect to achieve.
Thinking strategically is one of the goals for my leadership growth. I intend to improve my ability of seeing the big picture and learn to step back from daily tactical details of my practice and concentrate not only on the “how” and “what” but also on the “why.”By being a critical thinker, I will hold all my views and reasoning to intellectual reasoning standards. This will aid in reducing ambiguity and confusion in the understanding of ideas and thoughts. Achievement of this goal will place me at a suitable position thinking deeply and broadly. My thinking will be driven towards being adequate, precise, and logical for my intended purpose.
Schaffer, M. A., Sandau, K. E., & Diedrick, L. (2013). Evidence‐based practice models for organizational change: overview and practical applications. Journal of advanced nursing, 69(5), 1197-1209.
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New Graduate Nurse (NGN)
Transitioning from a student into a professional practitioner is a difficult experience for most people. However, the transition experience is especially difficult for graduate nurses who are ushered into a demanding work environment. Most new nurses are shocked at the sheer contrast between student life and work. Just a few weeks after employment, Graduate nurses are expected to take up serious responsibilities including patient care and supervisory duties.
This review explores literature on the New Graduate Nurse (NG) transition experience with the aim of discovering shortcomings in this knowledge area. This research hopes to bridge the gap in knowledge about self-care strategies that NGNs can use as the transition to Registered Nurses.
Background
Waves of research have studied the experiences of nurses as they transit from student to practicing Registered nurses. The first research wave focused on the experiences of individual nurses during the transition phase. The second wave, investigated the effectiveness of interventions meant to support nurses during the transition. Most studies into the experience of New Graduate Nurses (NGNs) used survey and interviews to arrive at their conclusions. The studies reported that NGNs initially found the role of practicing nurse extremely stressing and they reported many challenges.
However, role stress decreased as NGNs gained confidence, obtained clinical support and developed competence (Casey, Fink, Krugman, &Propst 2004; Halfer& Graf, 2006). NGNs described the transition as a difficult time filled with feeling or incompetence, fear of physicians, an overwhelming sense of responsibility, and difficulties in prioritizing, organizing or delegating tasks. Bowles and Candela (2005) carried a study in Nevada that sought to find the attrition rates of new nurse.
It was reported that approximately 30% of NGNs quit their first nursing jobs within the first year of employment. In just two years, 57% had moved from their first jobs. According to Bowles and Candela (2005), the high nurse turnover hinders work productivity, quality patient outcomes and the morale of the staff. Moreover, high turnover means healthcare organization have to incur the cost of rehiring and retraining new nurses to take the roles of those who leave.
While training more nurses may solve the nurse shortage problem, the problem of deficient patient care and supportive work environment needs to be handled to smooth the nurse transition. Casey et al (2004) found that NGNs are not satisfied with their working environment as they lamented the lack of a consistent preceptor, struggles with authority, a feeling of being undervalued, and workload issues. Chi, Laschinger and Wong (2006) carried out a study on transition among 226 nurses with less than 2 years practice experience.
The study reported similar results to Casey et al (2005); they indicated that there were high burnout rates among new nurses. The nurse complained about the lack of support, limitation of access to resources and opportunities as their main barrier to productivity at the transition phase. However, the job satisfaction outcomes of NGNs improved significantly after the first 18 months of practice. Halfer and Graf (2006) reported high job satisfaction rates among 84 subject of their research.
The two authors argued that nurse started to enjoy their work once they were able to organize their time, prioritize tasks, access resource, understand job expectation, and were made aware of the availability of professional development opportunities. Studies of nursing thought processes also indicate support the conclusion that the transition is a stressing time for graduate nurses.
According to Pellico, Brewer and Kovner (2009), NGNs’ confidence was initially low as they were unsure about the experience and knowledge , they also feared the interaction with patients as they felt they would not be able to understand their issues. NGNs were also worried about acting autonomously and deciding when it was necessary to call physicians. By the 9 month, NGNs had significantly boosted their confidence and were able to make competent patient care decisions.
The research wave on NGNs’ transition experience was followed by studies that investigated institutional initiatives to smooth the transition. The second wave was concerned with the preceptor and recognized him/her as a crucial component of the NGN transition process (Bowles and Candela, 2005). This phase of research proposed formal classes; evidence based practice, and guidance and mentoring as crucial precepts of nursing practice.
The studies proposed that all medical care should be involved in precepting, the presence of a designated preceptor and rewards for those who successfully carry out the preceptor’s role (Bowles and Candela, 2005). Some studies indicated that extended residencies and structured orientation to support the NGN transition improved job satisfaction and reduced the high nurse turnover. NGNs have complained about limited orientation, disorientation, feelings of confusion and loss, overwhelming responsibility as the main barriers to successful transitions.
The difficulties of the NGNs transition to practice are further complicated by other changes in their life (Scott, Engelke and Swanson, 2008). NGNs may have moved to a new town, become married or changed schools. Obviously, the new nurse transition face is fraught with difficult and there is need for support and self-management strategies to handle the stresses of this phase of a nurse’s career.
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Experiences of New Nurses
NGNs transitioning issues can be classified into four broad themes; demands on nurses, support at the workplace, the control of their role as employees, and perceptions of self efficacy (Bowles and Candela, 2005).
Workplace Demands
Demand in the workplace on new nurses is a theme that has been explored by many studies. NGNs identified workplace demands such as staff shortages, workload, decision making responsibilities and administrative duties as overwhelming issues (Casey et al, 2004). A survey of newly licensed nurses around the US found that demands relating to time were among the most stressing issues for NGNs. Nurses complained that they were often required to work hard or fast by their supervisors.
Casey et al (2004) also noted that nurses found it stressing to take responsibility for patient care provided by unregulated staff. Unfortunately, nursing has the dubious distinction of being the only profession which requires new practitioners to assume supervisory duties. Studies exploring the expectations of the multidisciplinary team working with new nurses reveal too high expectations of the (NGNs Waite, 2004). At eight weeks, the multidisciplinary team studied in the research expected new nurses to be able to make specific clinical assessments, be able to use laboratory data, and be able to react to emergencies (Dyess and Sherman, 2009).
In addition, the team expected the NGNs to be knowledgeable about the whole health systems. Many employers have complained about the deficit of key skills and the readiness of NGNs to deal with the demanding clinical environment. NGNs critical thinking skills and approaches to medication administration have also been called into question by some scholars. Romyn et al (2009) argued that NGNs are often responsible for near misses and medication errors as they are not proficient enough handle the medication demands of the job.
According to Edwards et al (2015), the concerns about the competence of NGNs are not unwarranted as competent performance is not guaranteed while working with graduate nurses. The lack of a consistent system to measure the performance of NGNs also further complicates the expectation of competence placed upon them. One of the common criteria for measuring competence in nursing is speed and ability to complete specific tasks (Romyn et al, 2009).
Unfortunately, the speed of New Graduate nurses may be quite low and they may not have the same capability to handle patient issues as experienced nurses (Delaney, 2003). This method of evaluating the performance of NGNs sees their work condemned as unsatisfactory and is often associated with stress among the new graduates joining the workforce.
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Control
Many NGNs report concerns about the control or autonomy of their new roles as practicing nurses. Many new nurses complained that being responsible and accountable to patients was stressing (Delaney, 2003). Duchscher and Cowin (2004) pointed out student nurse roles did little to equip NGNs for the responsibilities awaiting them in practice. Duchscher and Cowin (2004) support the view that patient care decision and outcome responsibilities often overwhelm new nurses.
However, the reactions of the NGNs varied as some embraced the new responsibilities, but most reported a feeling of being overwhelmed (Delaney, 2003). Researchers have argued that control is a double edged sword in the transition period. For nurses who embrace responsibility and accountability easily, it is exhilarating and exciting. In contrast, control brings about a feeling of anxiety for nurses who are unprepared for the new responsibilities.
NGNs may also suffer disorientation and poor sense of control as a result of unfamiliarity with the practice environment. NGNs are surprised when they realize that the practice environment is significantly different from the school context (Duchscher, 2001). Chang and Hancock (2003) argue that NGNs can experience as a result of uncertain expectation of the new role which gives rise to role ambiguity.
Support
Support by supervisors or coworkers plays a significant role in easing the NGN transition process. Often NGNs expend much effort in trying to familiarize themselves with existing workers in their healthcare setting (Casey et al, 2004). Duchscher and Cowin (2004) note that NGNs are in need the support of other members of the multidisciplinary team. Majority of NGNs report that there are adequately supported by preceptors and colleagues (Delaney, 2003).
They also reported that they felt part of the team. However, new nurse could not challenge established ways of doing things as they lacked support in doing this. Nurses also need support from family and friends outside the workplace. In fact, nurse reported that they performed better when they received support from outside the workplace.
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Self-efficacy
Casey et al (2004) reported that NGNs feel incompetent and inadequate as they begin practicing as nurses. Many new nurses report feeling as if they did not posses the necessary skills or knowledge to work as Registered Nurses (Delaney, 2003; Duchscher and Cowin, 2004). NGNs also greatly doubted their clinical competence as they lacked a frame of reference unlike experienced healthcare workers (Duchscher and Cowin, 2004). Duchscher and Cowin (2004) points out those NGNs felt their inadequate knowledge was a serious limitation. However, NGNs reported higher self-efficacy and confidence scores as they continued to gain clinical experience.
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Transition Impacts
Job stress
Job stress is one of the most widely reported results of the NGN transition (Delaney, 2003; Duchscher and Cowin, 2004; Twibell et al 2012; Pellico, Brewer and Kovner, 2009). Despite the emphasis on job stress in many studies, few have investigated the intensity of stress affecting NGNs. Chang and Hancock (2003) reported that the transition experience resulted in moderate amounts of stress among NGNs. According to Casey et al (2004), NGNs comfort and confidence is initially very high as the new graduates join the profession, however, it decreases with time in the job.
Fortunately, nurse comfort and confidence starts to increase as they gain experience and peaks one year after commencing practice. Chang and Hancock (2003) reported that nurses experience many stressors during the transition process. According to the two, the initial stressors include role ambiguity and responsibilities. After one year of employment, the main stressor is role overload.
Job Satisfaction
One of the most ignored outcomes of NGN transition is the job satisfaction impact. Common studies have emphasized on the challenges experienced during the transition phase but rarely have the satisfying job aspects being explored. Delaney (2003) reported that some new nurses reported that they found their new roles as practicing nurses satisfying. Nurse’s satisfaction with their work increased when they started to recognize available opportunities for personal growth and development.
Some NGNs reported that it felt exciting to finally take up the role of a practicing nurse. However, NGNs also reported many dissatisfying elements in their work, these included dizzying pace of work, inadequate staffing and too much autonomy and responsibility (Pellico, Brewer and Kovner, 2009; Casey et al, 2004; Chang and Hancock, 2003). Nurse who were satisfied with their work also were also more intent on staying with their employer.
Further research explored job satisfaction as an independent variable and presented interesting research findings. Delaney (2003) reported that nurses who were satisfied with their jobs felt a strong sense of belonging to the organization. Satisfaction in jobs was also negatively associated with role stress, role ambiguity and conflict during the transition process (Chang & Hancock, 2003).
Research has also explored outcomes such as turnover intent and nurse turnover. Many of these outcomes increase when there is shortage of nursing manpower. A high patient:nurse turnover is likely to precede and increase in patient mortality and has been indicated as an accelerator of nurse burnout (Bowles and Candela, 2005). Nurses report that the main causes of high turnover among NGNs are poor work design and emotional exhaustion.
These result support the need to research into self-management strategies that nurses can use to cope to the stressing experiences of the transition process. Twibell et al (2012) have hypothesized that self-care strategies may help nurse achieve higher levels of satisfaction with their jobs.
Interventions to support NGNs
Decades of research have popularized the notion that NGN transition is a process that needs to be addressed (Bowles and Candela, 2005). Many interventions have been applied to assist is making the transitioning process easy. However, there are few reports of intervention that aim to teach nurses how to self-manage the transition by performing recommended self-care practices.
Early studies recommended the use of internship programs and preceptor pairing to expose the nurse to the “real world” prior to commencing practice (Bowles and Candela, 2005). However, the value of preceptor and internship programs have come into questions recently and new research is needed to clarify the value they add to the NGN transition process.
One of the gaps in NGN transition research is the lack of measurement of the effectiveness of interventions to support NGN transition (Bowles and Candela, 2005). Many of the early studies, presented subjective results of the effectiveness of the interventions they were studying. Later studies in the late 1980s started to include quantitative measures of the effectiveness of the interventions (Casey et al 2004). However, most of the studies failed to measure the impact of the studies on patient outcome. Some of these studies are included in this review.
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Conclusion
The NGN transition process is a well researched area within the nursing profession. Most stakeholders seem to be aware of the problems that face NGNs as they transition into their practice. Decades of research present findings detailing mostly ineffective interventions to deal with the NGN transition process. One of the most common intervention experimented in research was the use of internship, residencies and preceptors. However, many researchers call into question the usefulness of these interventions in addressing the problems of new nurse’s commencing practice.
This research reveals two reasons why intervention to smooth the NGN transition failed to work despite decades of research. First, the early interventions were never objectively evaluated and thus the opportunity to gauge their effectiveness and increase their impact was missed. Furthermore, most of the intervention were designed to address problems identified in specific health care settings and were not backed by an understanding of the issues facing NGNs.
Few of the interventions sought to get to the bottom of the stress experienced by NGNs. Secondly, the interventions failed to take into consideration the many elements of the practice environment. This review presents some of the environmental factors that lead to a difficult experience for NGNs transitioning to practice. NGNs perception of their own abilities and knowledge is among the most stressing factors.
Many NGNs feel incompetent and inadequate when there are starting out. This attitude contrast sharply to the work demand, high expectation, and responsibility that characterize their work environment. Other healthcare workers expect nurses to exhibit the same level of competence and skills as experienced practitioners less than two months after being employed.
Few nurses are prepared for the sudden responsibility and autonomy they have over patient care decision. Many find the new responsibility overwhelming and are stressed. However, a substantial number of new nurses are excited and exhilarated to work autonomously. This review also indicates that support from colleagues, supervisors, family and friends are important for a successful transition. Nurses who receive support express confidence in their ability, Skills and knowledge.
This review has revealed that the NGN transition process can be an extremely stressing period. Many studies point to the stress and emotional distraught that is experienced by NGNs during the transition. Most studies report that new nurse feel overwhelmed by the demands of the new environment, feelings of inadequacy and fear of failure. Very few studies have investigated the possible positive impact of self-care mechanism that may assist nurse’s cope with the difficult transition period. This research will seek to address this gap in research and provide valuable evidence that may be used to improve the NGN transition experience significantly.
References
Bowles, C., & Candela, L. (2005). The first job experiences of recent RN graduates. Journal of Nursing Administration, 32(3), 130Y136.
Casey, K., Fink, R. R., Krugman, A. M., & Propst, F. J. (2004). The graduate nurse experience. Journal of Nursing Administration, 34(6), 303-311.
Cho, J., Laschinger, H., & Wong, C. (2006). Workplace empowerment, work engagement and organizational commitment of the new graduate nurses. Nursing Leadership, 19(3), 43Y60.
Duchscher, J. E. B., & Cowin, L. S. (2004). The experience of marginalization in new nursing graduates. Nursing Outlook, 52(6), 289-296.
Dyess, S. M., & Sherman, R. O. (2009). The first year of practice: New graduate nurses’ transition and learning needs. The Journal of Continuing Education in Nursing, 40(9), 403-410.
Edwards, D., Hawker, C., Carrier, J., & Rees, C. (2015). A systematic review of the effectiveness of strategies and interventions to improve the transition from student to newly qualified nurse.International journal of nursing studies, 52(7), 1254-1268.
Halfer, D., & Graf, E. (2006). Graduate nurse perceptions of the work experience. Nursing Economics, 24(3), 150.
Pellico, L. H., Brewer, C. S., & Kovner, C. T. (2009). What newly licensed registered nurses have to say about their first experiences.Nursing outlook, 57(4), 194-203.
Romyn, D. M., Linton, N., Giblin, C., Hendrickson, B., Houger Limacher, L., Murray, C., … & Weidner, A. (2009). Successful transition of the new graduate nurse. International Journal of Nursing Education Scholarship, 6(1).
Scott, E. S., Engelke, M. K., & Swanson, M. (2008). New graduate nurse transitioning: necessary or nice?. Applied Nursing Research,21(2), 75-83.
Twibell, R., St Pierre, J., Johnson, D., Barton, D., Davis, C., Kidd, M., & Rook, G. (2012). Tripping over the welcome mat: Why new nurses don’t stay and what the evidence says we can do about it. American Nurse Today, 7(6), 357-365.
Waite, R. (2004). Psychiatric nurses: Transitioning from student to advance beginner RN. Journal of the American Psychiatric Nurses Association, 10(4), 173-180.
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Hospice Nurse Transition
Business Plan
Executive Summary
Transitioning from a student into a professional practitioner is a difficult experience for most people. However, the transition experience is especially difficult for graduate nurses who are ushered into a demanding work environment. Most new nurses are shocked at the sheer contrast between student life and work. Just a few weeks after employment, Graduate nurses are expected to take up serious responsibilities including patient care and supervisory duties. This business plan sets out to bridge the gap in knowledge about self-care strategies that NGNs can use as they transition to hospice.
Business Plan-Transitioning Nurses into Hospice
1.0 Preliminary
1.1 Objectives
The business plan aims to educate the nurses that are transitioning into hospice on how to identify, explore, and improve our health and self-care practices. The plan will also help teams to evaluate risks for burnout and compassion fatigue, and learn more effective strategies for work and home-life balance. The self-management transition plan hopes to decrease attrition rates to zero in the next six months.
1.2 Philosophy Background
Hospice can be defined as a model of care formulated to afford comfy, and support to the patient as well as families especially when a life-limiting malady does not react to remedial prescriptions. The philosophywas startedin 1960 by Dr. Cicely Saunders, a British physician. The phrase “hospice” comes from the Latin word “hospital” that implies guesthouse. Today there are more than 4,100 hospice programs that offer this specialized care to patients.
1.3 Problem Statement
While the demands for hospice service are greater than the resources, it leads to nurses being put into the field to care for these patients too soon. However, experience demonstrates that nurses who transition into hospice are thoroughly orientated and trained on how to care for dying patients. In short, nurses tend to care deeply for others, at their peril. The underlying cause is that the nursing orientation and training lacks on self-care and time management, which ultimately results in compassion fatigue and high attrition for nurses in hospice. There is, however, there is a need to equip hospice transitioning NGNs’ with “Self-Management skills to decrease compassion fatigue and attrition rates.
2.0 Situation on the Ground
The Georgetown Hospice office is growing at a rapid rate in their patient census and so is the attrition rate with the nurses. This situation forces the current nurses to take on larger caseloads and more on call. Nurses are being hired, but most are new to the field of hospice, which requires some extra training. Often this training and orientation are not completed, due to the need of the new nurse in the field to help with patient coverage (Casey et al.2004).
The incomplete orientation can cause nurses to feel unsupported, inadequate and insecure. These feelings and emotions without the necessary skills or training on self-management lead to burnout, compassion fatigue and high attrition. Developing this self-management project will, in turn, help this office and company as a whole by saving the cost of new hires.
3.0 Critical Assumptions and Constraints
The Georgetown Hospice Leadership Team has all agreed that this self-management project will be essential to manage the growth of the office (Dyess & Sherman, 2009). The Leadership Team believes this project will build up the moral and confidence in the nurses. Decrease the amount of physical, psychological and emotional exhaustion felt by the nurses (Scott, Engelke & Swanson, 2008).
Predict the risk of compassion fatigue and give the tools to be successful in the field. This project will require collaboration and feedback between the Executive Director, Quality Manager, Manager of Clinical Practice and the RN Case managers. Some constraints are:
Conflicts in the nurses schedules- not all be able to meet at the same time
Inadequate nursing coverage- high patient to nurse ratio
Poor communication- limited feedback
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4.0 Key Success Factors
Educate the staff on coping strategies for facing death with assigned patients.
Encourage effective communication between managers and staff.
Schedule RN Case-mangers with sensible ratios that will allow the nurse to spend adequate time with patients to build rapport.
Incorporate burn-out prevention strategies in every monthly nursing meeting.
Team building to show the nurses a sense of belonging.
Teach Nurses to safeguard their boundaries.
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5.0 NGNs’ Experiences
Nurses experience difficulties when transitioning from student to practicing Registered Nurses. NGNs initially find the role of practicing nurse extremely stressing and challenging. However, role stress decrease as NGNs gain confidence, obtain clinical support and develop competence (Duchscher & Cowin, 2004).NGNs describe the transition as a difficult time filled with feeling or incompetence, fear of physicians, an overwhelming sense of responsibility, and difficulties in prioritizing, organizing or delegating tasks.
Approximately 30% of NGNs quit their first nursing jobs within the first year of employment. In just two years, 57% had moved from their first jobs (Duchscher & Cowin, 2004). The high nurse turnover hinders work productivity, quality patient outcomes and the morale of the staff. Moreover, high turnover means healthcare organization have to incur the cost of rehiring and retraining new nurses to take the roles of those who leave.
While training more nurses may solve the nurse shortage problem, the problem of deficient patient care and supportive work environment needs to be handled to smooth the nurse transition. However, NGNs are not satisfied with their working environment as they complain about the lack of a consistent preceptor, struggles with authority, a feeling of being undervalued, and workload issues (Delaney, 2003). There are high burnout rates among new nurses.
The nurse also complains about the lack of support, limited access to resources and opportunities as their main barrier to productivity at the transition phase. However, the job satisfaction outcomes of NGNs improve significantly after the first 18 months of practice. Nurses start to enjoy their work once they can organize their time, prioritize tasks, access resource, understand job expectation, and were made aware of the availability of professional development opportunities.
The transition is a stressing time for graduate nurses. NGNs’ confidence is initially low as they are unsure about the experience and knowledge; they also fear the interaction with patients as they feel they will not be able to understand their issues. NGNs are also worried about acting autonomously and deciding when it is necessary to call physicians (Twibell et al. 2012). Therefore, this business plan will demonstrate how to boost NGNs confidence and ability to make informed decisions about service delivery.
6.0 Management Summary
Key stakeholders for the project has been identified and interviewed to obtained and assess their requirements/needs, as well as input for successful implementation. Key stakeholders include Executive Director; Jackie Williams, Quality Manager; Anna Hamilton, Manager of Clinical Practice; Aneko Jackson and Manager of Clinical Practice Tracy Sudduth. All requirements were obtained, reviewed, prioritized, and approved by the project sponsor and team members(Bowles & Candela, 2005). Key Stakeholders, Executive Director; Jackie Williams, Quality Manager; Anna Hamilton, and Manager of Clinical Practice Tracy Sudduth, will be updated on a weekly basis in person or via telephone regarding the progress of the business plan.
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7.0 Strategy and Implementation
7.1 Strategies
7.1.2 Control
Many NGNs are concerned about the control or autonomy of their new roles as practicing nurses. In addition, they complain that being responsible and accountable to patients was stressing. Student nurse roles are inadequate in equipping NGNs for the responsibilities awaiting them in practice. Patient care decision and outcome responsibilities often overwhelm new nurses (Romyn et al.2009).
However, the reactions of the NGNs vary as some embrace the new responsibilities, but most report a feeling of being overwhelmed. Control is a double-edged sword in the transition period. For nurses who embrace responsibility and accountability easily, it is exhilarating and exciting. In contrast, control brings about a feeling of anxiety for nurses who are unprepared for the new responsibilities.
NGNs may also suffer disorientation and poor sense of control as a result of unfamiliarity with the practice environment. NGNs are surprised when they realize that the practice environment is significantly different from the school context (Chang & Hancock, 2003). NGNs can experience as a result of the uncertain expectation of the new role which gives rise to role ambiguity.
7.1.3 Support
Support by supervisors or coworkers plays a significant role in easing the NGN transition process. Often NGNs expend much effort in trying to familiarize themselves with existing workers in their healthcare setting. Moreover, NGNs are in need the support of other members of the multidisciplinary team. The majority of NGNs report that there are adequately supported by preceptors and colleagues, which makes them part of the team (Cho, Laschinger & Wong, 2006).
However, the new nurse cannot challenge established ways of doing things as they lack the necessary support. Nurses also need support from family and friends outside the workplace. In fact, nurse reports that they perform better when they receive external support.
Some of the interventions to support NGNs include teaching nurses to self-manage the transition by performing recommended self-care practices. The use of internship programs and preceptor pairing to expose the nurse to the “real world” before commencing practice is also effective (Halfer & Graf, 2006). Nonetheless, NGN transition research lacks anadequate measure of interventions to support the process.
7.1.4 Self-efficacy
NGNs feel incompetent and inadequate as they begin practicing as nurses. Many new nurses report feeling as if they do not possess the necessary skills or knowledge to work as RNs. NGNs also greatly double their clinical competence as they lack the basis, unlike experienced healthcare workers. Furthermore, NGNs feel that their inadequate knowledge was a severe limitation (Edwards et al, 2015). However, NGNs have a higher self-efficacy and confidence scores as they continue to gain clinical experience.
7.2 Implementation
There are three options considered in the development of this Self- Management Project.
1. Weekend training carried out once a month that would only focus on the well-being of the RN Case Managers (other disciplinary team members would also be welcomed). This time, would allow the nurses to reflect on challenges and solutions as a team (Pellico, Brewer & Kovner, 2009).
2. Develop a month long structured orientation that includes a week of orientation that is dedicated to healthy coping mechanisms in the field of hospice.
3. Incorporate the self- management education in the monthly nursing meetings and encourage a brief self-evaluation on current feelings and emotions weekly during IDG meetings.
After discussing all three options with the sponsors, option 3 was the most feasible and would not change the budget since these meetings are already included in the budget during the nurses normal work hours. Option one sounds good, but it defeats the purpose which is self-management; we want our nurses happy, we want them to relax when they are off and enjoy with their families.
This also increases the budget for extra overtime (Waite, 2004). A month-longorientation forces our veteran nurses to work that much longer with the high patient to nurse ratios. High ratios are very stressful to these nurses. We want our nurses to enjoy their employment with the company and allow them the opportunity to give quality care to patients.
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8.0 Financial Plan
8.1 Budget Estimate and Financial Analysis
The cost of this project is no added cost to the budget since the sponsors have requested that execution of this project is incorporatedinto the standard meetings.
8.2 Schedule Estimate
The Georgetown office has determined this is a critical need, due to the rapid growth in the census; therefore, the projection is to be completed by May 1, 2016. A time estimate has been provided to the project sponsors, and will be the responsibility of the Project Champion, to ensure the expected completion date is obtained.
9.0 Conclusion
The nursing career has a plethora of challenges especially for NGNs, who complain of limited orientation, disorientation, feelings of confusion and loss, overwhelming responsibility as the primary barriers to successful transitions. The difficulties of the NGNs transition to practice are further complicated by other changes in their life. The truth is that the new nurse transition face is fraught with difficult, and there is a need for support and self-management strategies to handle the stresses of this phase of a nurse’s career.
This care plan hinted about training to help fix anomaly. Formal classes; evidence-based practice, and guidance and mentoring as crucial precepts of nursing practice. As such, all medical care should be involved in presenting, the presence of a designated preceptor and rewards for those who successfully carry out the preceptor’s role. Again, extended residencies and structured orientation to support the NGN transition may improve job satisfaction and reduce the high nurse turnover.
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Casey, K., Fink, R. R., Krugman, A. M., & Propst, F. J. (2004). The graduate nurse experience. Journal of Nursing Administration, 34(6), 303-311.
Chang, E., & Hancock, K. (2003). Role stress and role ambiguity in new nursing graduates in Australia. Nursing & health sciences, 5(2), 155-163.
Cho, J., Laschinger, H., & Wong, C. (2006). Workplace empowerment, work engagement and organizational commitment of the new graduate nurses. Nursing Leadership, 19(3), 43Y60.
Delaney, C. (2003). Walking a fine line: Graduate nurses’ transition experiences during orientation. Journal of Nursing Education, 42(10), 437-443.
Duchscher, J. E. B., & Cowin, L. S. (2004). The experience of marginalization in new nursing graduates. Nursing Outlook, 52(6), 289-296.
Dyess, S. M., & Sherman, R. O. (2009). The first year of practice: New graduate nurses’ transition and learning needs. The Journal of Continuing Education in Nursing, 40(9), 403-410.
Edwards, D., Hawker, C., Carrier, J., & Rees, C. (2015). A systematic review of the effectiveness of strategies and interventions to improve the transition from student to newly qualified nurse.International journal of nursing studies, 52(7), 1254-1268.
Halfer, D., & Graf, E. (2006). Graduate nurse perceptions of the work experience. Nursing Economics, 24(3), 150.
Pellico, L. H., Brewer, C. S., & Kovner, C. T. (2009). What newly licensed registered nurses have to say about their first experiences.Nursing outlook, 57(4), 194-203.
Romyn, D. M., Linton, N., Giblin, C., Hendrickson, B., Houger Limacher, L., Murray, C. & Weidner, A. (2009). Successful transition of the new graduate nurse. International Journal of Nursing Education Scholarship, 6(1).
Twibell, R., St Pierre, J., Johnson, D., Barton, D., Davis, C., Kidd, M., & Rook, G. (2012). Tripping over the welcome mat: Why new nurses don’t stay and what the evidence says we can do about it. American Nurse Today, 7(6), 357-365.
Waite, R. (2004). Psychiatric nurses: Transitioning from student to advance beginner RN. Journal of the American Psychiatric Nurses Association, 10(4), 173-180.
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Transition Experience of New Graduate Nurses
Transitioning from a student into a professional practitioner is a difficult experience for most people. However, the transition experience is especially difficult for graduate nurses who are ushered into a demanding work environment. Most new nurses are shocked at the sheer contrast between student life and work. Just a few weeks after employment, Graduate nurses are expected to take up serious responsibilities including patient care and supervisory duties.
This review explores literature on the New Graduate Nurse (NG) transition experience with the aim of discovering shortcomings in this knowledge area. This research hopes to bridge the gap in knowledge about self-care strategies that NGNs can use as the transition to Registered Nurses.
Background
Waves of research have studied the experiences of nurses as they transit from student to practicing Registered nurses. The first research wave focused on the experiences of individual nurses during the transition phase. The second wave, investigated the effectiveness of interventions meant to support nurses during the transition. Most studies into the experience of New Graduate Nurses (NGNs) used survey and interviews to arrive at their conclusions. The studies reported that NGNs initially found the role of practicing nurse extremely stressing and they reported many challenges.
However, role stress decreased as NGNs gained confidence, obtained clinical support and developed competence (Casey, Fink, Krugman, &Propst 2004; Halfer& Graf, 2006). NGNs described the transition as a difficult time filled with feeling or incompetence, fear of physicians, an overwhelming sense of responsibility, and difficulties in prioritizing, organizing or delegating tasks. Bowles and Candela (2005) carried a study in Nevada that sought to find the attrition rates of new nurse.
It was reported that approximately 30% of NGNs quit their first nursing jobs within the first year of employment. In just two years, 57% had moved from their first jobs. According to Bowles and Candela (2005), the high nurse turnover hinders work productivity, quality patient outcomes and the morale of the staff. Moreover, high turnover means healthcare organization have to incur the cost of rehiring and retraining new nurses to take the roles of those who leave.
While training more nurses may solve the nurse shortage problem, the problem of deficient patient care and supportive work environment needs to be handled to smooth the nurse transition. Casey et al (2004) found that NGNs are not satisfied with their working environment as they lamented the lack of a consistent preceptor, struggles with authority, a feeling of being undervalued, and workload issues. Chi, Laschinger and Wong (2006) carried out a study on transition among 226 nurses with less than 2 years practice experience.
The study reported similar results to Casey et al (2005); they indicated that there were high burnout rates among new nurses. The nurse complained about the lack of support, limitation of access to resources and opportunities as their main barrier to productivity at the transition phase. However, the job satisfaction outcomes of NGNs improved significantly after the first 18 months of practice. Halfer and Graf (2006) reported high job satisfaction rates among 84 subject of their research.
The two authors argued that nurse started to enjoy their work once they were able to organize their time, prioritize tasks, access resource, understand job expectation, and were made aware of the availability of professional development opportunities. Studies of nursing thought processes also indicate support the conclusion that the transition is a stressing time for graduate nurses.
According to Pellico, Brewer and Kovner (2009), NGNs’ confidence was initially low as they were unsure about the experience and knowledge , they also feared the interaction with patients as they felt they would not be able to understand their issues. NGNs were also worried about acting autonomously and deciding when it was necessary to call physicians. By the 9 month, NGNs had significantly boosted their confidence and were able to make competent patient care decisions.
The research wave on NGNs’ transition experience was followed by studies that investigated institutional initiatives to smooth the transition. The second wave was concerned with the preceptor and recognized him/her as a crucial component of the NGN transition process (Bowles and Candela, 2005). This phase of research proposed formal classes; evidence based practice, and guidance and mentoring as crucial precepts of nursing practice.
The studies proposed that all medical care should be involved in precepting, the presence of a designated preceptor and rewards for those who successfully carry out the preceptor’s role (Bowles and Candela, 2005). Some studies indicated that extended residencies and structured orientation to support the NGN transition improved job satisfaction and reduced the high nurse turnover. NGNs have complained about limited orientation, disorientation, feelings of confusion and loss, overwhelming responsibility as the main barriers to successful transitions.
The difficulties of the NGNs transition to practice are further complicated by other changes in their life (Scott, Engelke and Swanson, 2008). NGNs may have moved to a new town, become married or changed schools. Obviously, the new nurse transition face is fraught with difficult and there is need for support and self-management strategies to handle the stresses of this phase of a nurse’s career.
Experiences of New Nurses
NGNs transitioning issues can be classified into four broad themes; demands on nurses, support at the workplace, the control of their role as employees, and perceptions of self efficacy (Bowles and Candela, 2005).
Workplace Demands
Demand in the workplace on new nurses is a theme that has been explored by many studies. NGNs identified workplace demands such as staff shortages, workload, decision making responsibilities and administrative duties as overwhelming issues (Casey et al, 2004). A survey of newly licensed nurses around the US found that demands relating to time were among the most stressing issues for NGNs. Nurses complained that they were often required to work hard or fast by their supervisors.
Casey et al (2004) also noted that nurses found it stressing to take responsibility for patient care provided by unregulated staff. Unfortunately, nursing has the dubious distinction of being the only profession which requires new practitioners to assume supervisory duties. Studies exploring the expectations of the multidisciplinary team working with new nurses reveal too high expectations of the (NGNs Waite, 2004). At eight weeks, the multidisciplinary team studied in the research expected new nurses to be able to make specific clinical assessments, be able to use laboratory data, and be able to react to emergencies (Dyess and Sherman, 2009).
In addition, the team expected the NGNs to be knowledgeable about the whole health systems. Many employers have complained about the deficit of key skills and the readiness of NGNs to deal with the demanding clinical environment. NGNs critical thinking skills and approaches to medication administration have also been called into question by some scholars. Romyn et al (2009) argued that NGNs are often responsible for near misses and medication errors as they are not proficient enough handle the medication demands of the job.
According to Edwards et al (2015), the concerns about the competence of NGNs are not unwarranted as competent performance is not guaranteed while working with graduate nurses. The lack of a consistent system to measure the performance of NGNs also further complicates the expectation of competence placed upon them. One of the common criteria for measuring competence in nursing is speed and ability to complete specific tasks (Romyn et al, 2009).
Unfortunately, the speed of New Graduate nurses may be quite low and they may not have the same capability to handle patient issues as experienced nurses (Delaney, 2003). This method of evaluating the performance of NGNs sees their work condemned as unsatisfactory and is often associated with stress among the new graduates joining the workforce.
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Control
Many NGNs report concerns about the control or autonomy of their new roles as practicing nurses. Many new nurses complained that being responsible and accountable to patients was stressing (Delaney, 2003). Duchscher and Cowin (2004) pointed out student nurse roles did little to equip NGNs for the responsibilities awaiting them in practice. Duchscher and Cowin (2004) support the view that patient care decision and outcome responsibilities often overwhelm new nurses.
However, the reactions of the NGNs varied as some embraced the new responsibilities, but most reported a feeling of being overwhelmed (Delaney, 2003). Researchers have argued that control is a double edged sword in the transition period. For nurses who embrace responsibility and accountability easily, it is exhilarating and exciting. In contrast, control brings about a feeling of anxiety for nurses who are unprepared for the new responsibilities.
NGNs may also suffer disorientation and poor sense of control as a result of unfamiliarity with the practice environment. NGNs are surprised when they realize that the practice environment is significantly different from the school context (Duchscher, 2001). Chang and Hancock (2003) argue that NGNs can experience as a result of uncertain expectation of the new role which gives rise to role ambiguity.
Support
Support by supervisors or coworkers plays a significant role in easing the NGN transition process. Often NGNs expend much effort in trying to familiarize themselves with existing workers in their healthcare setting (Casey et al, 2004). Duchscher and Cowin (2004) note that NGNs are in need the support of other members of the multidisciplinary team. Majority of NGNs report that there are adequately supported by preceptors and colleagues (Delaney, 2003).
They also reported that they felt part of the team. However, new nurse could not challenge established ways of doing things as they lacked support in doing this. Nurses also need support from family and friends outside the workplace. In fact, nurse reported that they performed better when they received support from outside the workplace.
Self-efficacy
Casey et al (2004) reported that NGNs feel incompetent and inadequate as they begin practicing as nurses. Many new nurses report feeling as if they did not posses the necessary skills or knowledge to work as Registered Nurses (Delaney, 2003; Duchscher and Cowin, 2004). NGNs also greatly doubted their clinical competence as they lacked a frame of reference unlike experienced healthcare workers (Duchscher and Cowin, 2004). Duchscher and Cowin (2004) points out those NGNs felt their inadequate knowledge was a serious limitation. However, NGNs reported higher self-efficacy and confidence scores as they continued to gain clinical experience.
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Transition Impacts
Job stress
Job stress is one of the most widely reported results of the NGN transition (Delaney, 2003; Duchscher and Cowin, 2004; Twibell et al 2012; Pellico, Brewer and Kovner, 2009). Despite the emphasis on job stress in many studies, few have investigated the intensity of stress affecting NGNs. Chang and Hancock (2003) reported that the transition experience resulted in moderate amounts of stress among NGNs. According to Casey et al (2004), NGNs comfort and confidence is initially very high as the new graduates join the profession, however, it decreases with time in the job.
Fortunately, nurse comfort and confidence starts to increase as they gain experience and peaks one year after commencing practice. Chang and Hancock (2003) reported that nurses experience many stressors during the transition process. According to the two, the initial stressors include role ambiguity and responsibilities. After one year of employment, the main stressor is role overload.
Job Satisfaction
One of the most ignored outcomes of NGN transition is the job satisfaction impact. Common studies have emphasized on the challenges experienced during the transition phase but rarely have the satisfying job aspects being explored. Delaney (2003) reported that some new nurses reported that they found their new roles as practicing nurses satisfying. Nurse’s satisfaction with their work increased when they started to recognize available opportunities for personal growth and development.
Some NGNs reported that it felt exciting to finally take up the role of a practicing nurse. However, NGNs also reported many dissatisfying elements in their work, these included dizzying pace of work, inadequate staffing and too much autonomy and responsibility (Pellico, Brewer and Kovner, 2009; Casey et al, 2004; Chang and Hancock, 2003). Nurse who were satisfied with their work also were also more intent on staying with their employer.
Further research explored job satisfaction as an independent variable and presented interesting research findings. Delaney (2003) reported that nurses who were satisfied with their jobs felt a strong sense of belonging to the organization. Satisfaction in jobs was also negatively associated with role stress, role ambiguity and conflict during the transition process (Chang & Hancock, 2003).
Research has also explored outcomes such as turnover intent and nurse turnover. Many of these outcomes increase when there is shortage of nursing manpower. A high patient:nurse turnover is likely to precede and increase in patient mortality and has been indicated as an accelerator of nurse burnout (Bowles and Candela, 2005). Nurses report that the main causes of high turnover among NGNs are poor work design and emotional exhaustion.
These result support the need to research into self-management strategies that nurses can use to cope to the stressing experiences of the transition process. Twibell et al (2012) have hypothesized that self-care strategies may help nurse achieve higher levels of satisfaction with their jobs.
Interventions to support NGNs
Decades of research have popularized the notion that NGN transition is a process that needs to be addressed (Bowles and Candela, 2005). Many interventions have been applied to assist is making the transitioning process easy. However, there are few reports of intervention that aim to teach nurses how to self-manage the transition by performing recommended self-care practices.
Early studies recommended the use of internship programs and preceptor pairing to expose the nurse to the “real world” prior to commencing practice (Bowles and Candela, 2005). However, the value of preceptor and internship programs have come into questions recently and new research is needed to clarify the value they add to the NGN transition process.
One of the gaps in NGN transition research is the lack of measurement of the effectiveness of interventions to support NGN transition (Bowles and Candela, 2005). Many of the early studies, presented subjective results of the effectiveness of the interventions they were studying. Later studies in the late 1980s started to include quantitative measures of the effectiveness of the interventions (Casey et al 2004). However, most of the studies failed to measure the impact of the studies on patient outcome. Some of these studies are included in this review.
Conclusion
The NGN transition process is a well researched area within the nursing profession. Most stakeholders seem to be aware of the problems that face NGNs as they transition into their practice. Decades of research present findings detailing mostly ineffective interventions to deal with the NGN transition process. One of the most common intervention experimented in research was the use of internship, residencies and preceptors. However, many researchers call into question the usefulness of these interventions in addressing the problems of new nurse’s commencing practice.
This research reveals two reasons why intervention to smooth the NGN transition failed to work despite decades of research. First, the early interventions were never objectively evaluated and thus the opportunity to gauge their effectiveness and increase their impact was missed. Furthermore, most of the intervention were designed to address problems identified in specific health care settings and were not backed by an understanding of the issues facing NGNs.
Few of the interventions sought to get to the bottom of the stress experienced by NGNs. Secondly, the interventions failed to take into consideration the many elements of the practice environment. This review presents some of the environmental factors that lead to a difficult experience for NGNs transitioning to practice. NGNs perception of their own abilities and knowledge is among the most stressing factors.
Many NGNs feel incompetent and inadequate when there are starting out. This attitude contrast sharply to the work demand, high expectation, and responsibility that characterize their work environment. Other healthcare workers expect nurses to exhibit the same level of competence and skills as experienced practitioners less than two months after being employed.
Few nurses are prepared for the sudden responsibility and autonomy they have over patient care decision. Many find the new responsibility overwhelming and are stressed. However, a substantial number of new nurses are excited and exhilarated to work autonomously. This review also indicates that support from colleagues, supervisors, family and friends are important for a successful transition. Nurses who receive support express confidence in their ability, Skills and knowledge.
This review has revealed that the NGN transition process can be an extremely stressing period. Many studies point to the stress and emotional distraught that is experienced by NGNs during the transition. Most studies report that new nurse feel overwhelmed by the demands of the new environment, feelings of inadequacy and fear of failure. Very few studies have investigated the possible positive impact of self-care mechanism that may assist nurse’s cope with the difficult transition period. This research will seek to address this gap in research and provide valuable evidence that may be used to improve the NGN transition experience significantly.
References
Bowles, C., & Candela, L. (2005). The first job experiences of recent RN graduates. Journal of Nursing Administration, 32(3), 130Y136.
Casey, K., Fink, R. R., Krugman, A. M., & Propst, F. J. (2004). The graduate nurse experience. Journal of Nursing Administration, 34(6), 303-311.
Chang, E., & Hancock, K. (2003). Role stress and role ambiguity in new nursing graduates in Australia. Nursing & health sciences, 5(2), 155-163.
Cho, J., Laschinger, H., & Wong, C. (2006). Workplace empowerment, work engagement and organizational commitment of the new graduate nurses. Nursing Leadership, 19(3), 43Y60.
Duchscher, J. E. B., & Cowin, L. S. (2004). The experience of marginalization in new nursing graduates. Nursing Outlook, 52(6), 289-296.
Dyess, S. M., & Sherman, R. O. (2009). The first year of practice: New graduate nurses’ transition and learning needs. The Journal of Continuing Education in Nursing, 40(9), 403-410.
Edwards, D., Hawker, C., Carrier, J., & Rees, C. (2015). A systematic review of the effectiveness of strategies and interventions to improve the transition from student to newly qualified nurse.International journal of nursing studies, 52(7), 1254-1268.
Halfer, D., & Graf, E. (2006). Graduate nurse perceptions of the work experience. Nursing Economics, 24(3), 150.
Pellico, L. H., Brewer, C. S., & Kovner, C. T. (2009). What newly licensed registered nurses have to say about their first experiences.Nursing outlook, 57(4), 194-203.
Romyn, D. M., Linton, N., Giblin, C., Hendrickson, B., Houger Limacher, L., Murray, C., … & Weidner, A. (2009). Successful transition of the new graduate nurse. International Journal of Nursing Education Scholarship, 6(1).
Scott, E. S., Engelke, M. K., & Swanson, M. (2008). New graduate nurse transitioning: necessary or nice?. Applied Nursing Research,21(2), 75-83.
Twibell, R., St Pierre, J., Johnson, D., Barton, D., Davis, C., Kidd, M., & Rook, G. (2012). Tripping over the welcome mat: Why new nurses don’t stay and what the evidence says we can do about it. American Nurse Today, 7(6), 357-365.
Waite, R. (2004). Psychiatric nurses: Transitioning from student to advance beginner RN. Journal of the American Psychiatric Nurses Association, 10(4), 173-180.
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