Professional Transitions in Nursing

A guide to practice in the Australian healthcare system

Alister Hodge, Wayne Varndell

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000246926
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Written by clinical lecturers, Professional Transitions in Nursing provides a practical and accessible guide to the core knowledge and skills required by nurse graduates entering the Australian workforce for the first time. Part I focuses on the structure of the Australian healthcare system and the national competency standards. The authors examine key issues including ethics, law and codes of conduct as well as the leadership, team-building and communication skills necessary in a constantly changing and high-pressure environment. Part II outlines the clinical skills and practices a nurse graduate must master including clinical assessment, risk management and reporting, management plans, diagnostics reasoning, collaboration with other health professionals and working with patients from diverse backgrounds. A special feature is an analysis of issues in Aboriginal and Torres Strait Islander nursing practice. The authors also outline health information systems and technologies and how to utilise these most effectively. Part III looks at career planning and lifelong learning with advice on applying for a nursing position and continual professional development. This is an essential reference for both nursing graduates and overseas qualified nurses seeking to pursue a career in Australia. 'This text will be of tremendous use to new graduate nurses, nurses relocating from overseas and those of us who support these nurses during their transitions. The language is easily accessible and important content about everyday nursing practice is discussed in a practical and logical way. A particular strength is the use of research to support key points of discussion.'
Professor Andrea Marshall, Professor of Acute and Complex Care Nursing, Griffith University'This book is a must-have for undergraduates, newly graduated and overseas qualified registered nurses entering the Australian healthcare workforce for the first time. Written by experienced nurses, the book provides essential up-to-date information that is presented in an easily accessible way. I highly recommend this book.'
Associate Professor Jacqueline Bloomfield, Sydney Nursing School, University of Sydney 'For educators supporting student, new graduate and international graduate nurses, this text will be an important resource and is superbly structured to guide curriculum development and delivery.'
Dr Danny Hills, Senior Lecturer, School of Nursing and Midwifery, Monash University

PART I
THE AUSTRALIAN HEALTH SYSTEM, PROFESSIONAL STANDARDS AND LEGISLATION

1
THE TRANSITION TO REGISTERED NURSE

Alister Hodge

In this chapter, you will develop an understanding of:

• challenges facing the new graduate nurse
• new graduate nurse scope of practice and role boundaries
• developing professional identity
• strategies to support your transition to the workplace
• adapting to shiftwork, sleep hygiene and maintaining a work–life balance
• managing personal stress.

CHALLENGES FACING THE NEW GRADUATE NURSE

As nurse graduates, the first year in the health workforce will involve a major transi tion from being a student to taking on the responsibilities of a Registered Nurse (RN). The authors’ own experience as graduates, together with the experi ences of the many nurses we have been privileged to support during their transition to practice, informs this book.

During transition, each graduate will experience different issues that may be challenging on a personal level—for example, learning how to manage fatigue on a rotating shift roster, and developing time-management skills on a busy ward. You will share many challenges with your fellow graduates, such as adjusting to a new workplace culture, interacting with complex technology and developing functional communication patterns. It can be a steep learning curve!

Registration as a nurse changes your world significantly. Adjusting to the cultural differences between university and hospital environments presents an initial challenge as you move from the familiar role of a student to that of an accountable, practising RN (Johnstone et al., 2008). You will exchange the defined support structures of a university for a constantly evolving clinical environ ment without the guarantee of mentorship or support (Phillips et al., 2014). In addition, you may experience a degree of stress due to uncertainty about your role and a lack of clearly defined responsibilities, making it difficult to know what is expected of you (Chang & Hancock, 2003).

All new graduates entering the acute care setting face the contemporary health challenges of rising patient acuity, shorter lengths of stay, complex technologies such as monitors and electronic documentation, compounded by an intimate exposure to end-of-life situations (Walker et al. 2013). Some work sites may have poor staffing ratios that contribute to heavy workloads, issues with skill mix and an increased likelihood of being asked to manage complex patients whose conditions stretch your knowledge and skill set. The pressure is such that research by Dyess and Sherman (2009) found some new graduate nurses were concerned they might not be able to provide safe care and concurrently meet the expectations of their employer.

acuity Relates to the intensity of nursing care required by the patient.

In the interests of delivering safe patient care, you must learn to effectively communicate with other members of staff, including doctors and allied health professionals. Failures in communication may result in important information being missed and increased patient risk. (Patterns of communication that help information transfer are discussed in depth in Chapter 6.) Although it may take some time for you to feel confident about expressing yourself—particularly with senior clinicians—it is a fundamental skill that will be required throughout the course of your nursing career. In addition to discussing clinical information, you may have to supervise and delegate aspects of care to Assistants in Nursing (AIN) and Enrolled Nurses (EN), who may be older and have more years of practice in the health workforce (Dyess & Sherman, 2009).

Early in your graduate year, you may encounter ‘reality shock’, finding major discrepancies between what you understood about nursing during your undergraduate education and your real-life experience of nursing in the clinical environment. In some cases, you may be forced to prioritise tasks that ensure basic patient safety at the expense of meaningful interactions, such as patient education regarding their illness and treatment that will allow the patient to become a true contributor to their own health. This conflict between what you are asked to do as an RN and what you were taught to consider as key priorities in your undergraduate degree may cause dissatisfaction and disillusionment, and in some cases results in graduates leaving the profession (Duchscher, 2009). This period of ‘reality shock’ usually occurs in the first four to six months of practice. Although the new graduate may lose their idealised version of the nurse’s role, interestingly it often coincides with them starting to become more confident in their ability to undertake a more holistic role that is not purely limited to routine tasks (Missen et al., 2014).

For a profession that prides itself on ‘caring’ for patients, it is disappointing that bullying, victimisation and undermining by other staff has been found to be a common experience for new graduate nurses. Even when bullying is not overt, lacking support structures can leave you feeling that you are not part of the nursing team (Duchscher, 2009). Methods to combat bullying are discussed in detail in Chapter 6.

Aside from the challenges of care provision and interacting with the health team, you will experience many other life-changing events. For example, adjusting to a rotating roster inclusive of night shifts can lead to physical and mental exhaustion, and invariably places strain on family relationships by altering living arrangements and household patterns.

EXPECTATIONS OF THE NEW GRADUATE, SCOPE OF PRACTICE AND ROLE BOUNDARIES

Historically, nurse employers have frequently complained that new graduates are inadequately prepared for clinical practice, with many institutions having an un realistic expectation that a new graduate can ‘hit the ground running’ at the practice level of a seasoned RN (Phillips et al., 2014). Much research has focused on a theory–practice gap and inadequate university preparation of students, but interestingly this complaint also existed when nurses were trained exclusively within hospitals (Haddad et al., 2013). The take-home message for you as a graduate is that no matter what the profession or training system may be, everyone faces a steep learning curve on entry to their chosen career.

When institutions, other staff and new graduates themselves have unrealistic expectations about their ability to perform at a high level immediately on entering the workforce, stress invariably results. This has significant wider implications for the nursing profession, which already suffers from staff shortages, as new graduates who experience high levels of stress are more likely to have increased rates of sick leave, poor work satisfaction and an increased likelihood of leaving nursing altogether (Chang & Hancock, 2003).

The university undergraduate qualification prepares the student to a beginner level of practice. Australian universities base degree curricula on the Nursing and Midwifery Board of Australia (NMBA) National Competency Standards for Registered Nurses (discussed in Chapter 4). The NMBA considers the RN to be a professional capable of critical thinking, who is able to accurately assess patient needs to provide evidence-based, holistic and collaborative health management across a range of settings. With the award of registration, the new graduate nurse is considered to be safe and competent at a novice level (Haddad et al., 2013). Being new to the clinical environment, you cannot be expected to have knowledge and understanding of situations with which you are coming into contact for the first time. Employers must be mindful that new graduates are entering a period of intensive learning that requires dedi cated support.

A rational starting point for novice-level clinical practice is being able to provide safe patient care. It is also desirable that during the first year of employment, you consolidate the knowledge and skill base acquired during your degree, adapt to the health workplace culture, and achieve a balance between work and personal demands. To achieve these expectations, employers are beginning to note the importance of finding new graduates who already possess generic skills such as communication, problem-solving and enthusiasm (Walker et al., 2013). Four key attributes that demonstrate your work readiness are:

1. social intelligence: the ability to communicate with a range of people, work in teams, manage interpersonal conflict, and seek support when needed
2. organisational acumen: having knowledge of the ward, hospital policy and procedures, together with maturity and a willingness to engage in ongoing professional development
3. work competence: having basic clinical skills for patient management supported by sufficient theoretical knowledge to understand the basis of your practice, experience commensurate with a beginning practitioner, the confidence to use and implement the knowledge you have gained and an awareness of its limitations, and willingness to be responsible for your treatment decisions
4. personal characteristics: resilience and flexibility to cope with changing work-place demands and challenges, and the ability to manage your own stress to maintain a healthy work–life balance (Walker et al., 2013).

Initially, you will most likely question the scope of practice within which you are permitted to work. Simply put, the extent of any nurse’s scope of practice is determined by their education, training and competence (NMBA, 2010). As all nurses are accountable for their own actions, this means you must consider whether you have the required knowledge to complete the task safely prior to completing a specific action. If the answer to this question is ‘no’, then you should not undertake the activity until the appropriate education and supervision are acquired. The extent of the nurse’s scope of practice is then influenced in the clinical setting by the organisational policies, quality and risk-management framework and requirements of their site of employment (NMBA, 2010). This means that in some cases, despite having an adequate knowledge set to complete a task safely, the local policy states that the nurse is not permitted to undertake the named activity, or that the education will not be provided for a given task until the nurse has met a certain development milestone. In most cases, this is designed to protect the new nurse from a more onerous workload until they are comfortably proficient with the basic nursing care of their patients. One example involves the procedure of intravenous cannulation. In some emergency departments, new graduate nurses are not permitted to cannulate until they have completed four months of their placement. This allows the new graduate to concentrate on core nursing duties prior to taking on extended roles that may also be completed by the treating doctor.

DEVELOPING PROFESSIONAL IDENTITY

It is important for you to develop a positive professional identity. Professional identity is linked to, yet different from, your overall self-concept as an individual (who you think you are). It is a sense of self that is acquired from the role and work that you complete as a nurse, and is influenced by interactions with others as well as your position in society (Cowin et al., 2013). Developing a professional identity requires you to successfully combine your own values and personal attributes with those of the nursing profession. A positive professional identity has been noted as being important for staff retention, job satisfaction and patient care, and is also linked to increased resilience regarding pressures in the nursing role and improved self-efficacy (Cowin et al., 2013; Johnson et al., 2012; Madsen et al., 2009; McAllister et al., 2009).

Professional identity in...