Challenges faced by Newly Qualified Nurses
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It is estimated that approximately 60% of the nursing workforce consists of newly qualified nurses: consequently there is much literature that examines the transitions that individuals experience as they progress from the student nurse to the newly qualified nurse (Whitehead, 2001; 2011). The recruitment and retention of nurses globally is a major issue, and hence healthcare systems need to address how best to ensure smooth transition into the professional nurse role to ensure newly qualified nurses successfully adjust into their new roles (Duchscher, 2008). In facilitating such transitions, great emphasis has been placed upon providing effective work environments in which newly qualified nurses can be best supported through the use of supervisors and preceptorship, and in having their views acknowledged and valued (Department of Health, DoH, 2008; Nursing and Midwifery Council, 2006). Indeed the policy paper, 'A High Quality Workforce' (DoH, 2008) specifically acknowledged the role that the National Health System must adopt in improving not simply the quality of care but also the quality of support offered to NHS staff. Key DoH (2008) recommendations were placed on establishing more effective nursing training to ensure newly qualified nurses were better prepared for the realities of nursing practice, and providing avenues for appropriate continued professional development. However, studies still highlight that in reality, newly qualified nurses' experiences are not aligned with these recommendations and nurses are still experiencing great challenges and difficulties in adjusting to the newly qualified nurse role (Mooney, 2007; Nash et al. 2009). The aim of this essay therefore is to examine the challenges that newly qualified nurses' experience as they make their transitions into professional nursing practice, and to explore particular evidence based strategies to facilitate effective adjustment to their new role.
Nursing role transitions
The difficulties that student nurses experience in making the transition to newly qualified nurse has been highlighted by both the Department of Health (DoH, 2007) and the Nursing and Midwifery Council (NMC, 2006) who raise concerns around whether such nurses are being appropriately prepared to feel confident and competent in their new nursing positions. As the NHS ethos of the 6 Cs of care demonstrates, competence, and the courage to act with confidence, alongside communication, collaboration and continuity, are essential aspects of the nurses' role in order to practice effectively (NHS, 2013). The literature indicates however that student nurses are simply not being effectively supported by both the NHS health care system and pre-registration training, which is leading to ineffective training which results in poorly prepared student nurses with expectations that do not translate into their actual new 'professional' nursing roles (Mooney, 2007; O'Shea and Kelly 2007). As Clark and Holmes (2007, p.1211) state, nursing education does not offer students "the knowledge, skills or confidence necessary for independent practice". As O'Shea and Kelly (2007) also highlight, newly qualified nurses' transitions are further challenged by little knowledge of the diverse roles qualified nurses engage within, such as managerial, leadership, decision-making and clinical duties. Studies however reveal that amongst newly qualified nurses there are similar, shared personal values based on altruistic values of desiring to help, care and support patients', which promotes the person-centred model of care (DoH, 2000). However studies highlight that in practice, organisational constraints (Lack of time and staffing problems) combined with managers' high expectations create challenges for new nurses in implementing theoretical knowledge and personal values into practice (Mackintosh, 2006). Therefore there is much need to determine key strategies that can promote effective transitions for nurses to help them to negotiate new positions as newly qualified nurses that prevent disillusionment, frustration, stress and potential burnout (Mackintosh, 2006).
The shock of transition
Duchscher (2008) identifies two key processes, those of socialisation and professionalisation, that occur as student nurses adjust to becoming a newly qualified nurse, Duchscher states that in order for nurses to effectively adjust to the transition they must modify their professional and personal values so that they are more aligned with the actual role. Duchscher (2008) argues that these changes result in nurses experiencing a process of intellectual, emotive personal, professional, role, skill and relationship transitions, which lead to new understandings, expectations and, subsequently, experiences. Studies corroborate this by highlighting that the first three months of becoming a newly qualified nurse have been reported by such nurses to be a sharp shock, as prior expectations of theory-based nursing are challenged by having such ideals of person-centred care made often impossible through different care practices expected within NHS settings being reinforced within health care teams (Kelly and Ahern, 2009; Hollywood, 2011). As multi-disciplinary teamwork in NHS care systems is a key aspect of NHS policy (DoH, 2010; NHS, 2013), newly qualified nurses can feel coerced into adopting different care practices that challenge their theoretical understanding of best practice, which can lead to tensions and, as studies reveal, could lead to distrust and poor staff morale (McDonald, Jayasuriya, and Harris, 2012). The literature evidences that newly qualified nurses who feel pressured to follow the practices of other staff can become desensitised to the use of poor practice through rationalising the need for such practice as a result of environmental pressures, such as time or staffing issues, which can lead to the nurse also adopting them (Mackintosh, 2006). Mackintosh (2006) highlights how this can lead to newly qualified nurses re-negotiating new nursing roles where personal values are re-assessed to enable adoption of similar practices, which serves to further reinforce the use of poor care within NHS settings.
Consequently as Kelly and Ahern (2009) identified, it is no wonder that newly qualified nurses report finding the transitional process overwhelming and stressful, confirming Mooney's (2007) findings that nurses are unprepared and experiencing unexpected difficulties. Whitehead (2011) and Scully (2011) argue that such difficulties are a result of a theory-practice gap, which leads to nurses experiencing a conflict amongst theoretical, personal and professional values (Maben, Latter and Clark, 2006). Mooney (2007) confirms this in research conducted with newly qualified nurses that reported that pre-registration training did not prepare them for the realities of actual practice. Mooney (2007) also demonstrated how the high expectations of staff-leaders and patients furthered nurses' feeling of lacking skills and knowledge, as no accommodation was made for their newly qualified status and lack of experience, which led to stress and disillusionment (Hollywood, 2011). As Maben et al. (2006) state, such treatment and lack of support places newly qualified nurses in vulnerable situations: they are at great disadvantage due to lack of experience and appropriate support strategies (Hollywood, 2011).
Addressing stress and expectations
Whilst studies highlight the difficulties that nurses experience in adjusting to the newly qualified nurse role (Whitehead, 2001; 2011), Edwards et al.(2011) reveal that appropriate support can minimise student nurses' anxiety and help to build confidence through enhancing greater understanding of their role and staff demonstrating acceptance within nursing teams. However, Edwards et al. (2011) identify that staffing issues, staff attitudes and time constraints often lead to such nurses being unsupported, and can foster inequalities across NHS settings in the level of support provided. Scully (2011) emphasises that in order to provide appropriate support to newly qualified nurses, the political, social, and cultural barriers inherent in such a context must be addressed to help such nurses to overcome the theory-practice gap. As Fenwick et al. (2012) recommend, staff support needs to support a re-negotiation of newly qualified nurses' expectations – resulting from theoretical training – to offer contexts in which discussions can be promoted that can address unrealistic expectations of the newly qualified nurse's role so that what Kramer (1974) terms as reality shock is prevented. Theory-practice gaps, if strategies are not developed, can lead to segregation across newly qualified nurses and experienced staff, as when high expectations are placed upon newly qualified staff, they are unable to re-negotiate their new roles as they have no understanding of how their role can be limited by the particular socio-political and organisational constraints that can impede their practice (Maben et al. 2006).
Supportive work environments
Consequently the actual NHS environment and organisational culture in which newly qualified nurses find themselves can elicit a major impact upon how such nurses manage their transitions and forge a new self-identity and come to make sense of the role of the newly qualified nurse (Mooney, 2007; Whitehead, 2001). A key strategy promoted by the Nursing and Midwifery Council (NMC) (2006) is the employment of preceptors and supervisors to facilitate newly qualified nurses' adjustment to their new practice settings (NMC 2006). Preceptorship within a nurse's first year of professional practice can be utilised to highlight newly qualified nurses' existing strengths and weaknesses, so that areas of development can be highlighted and addressed. However, it can also provide a valuable context in which fears, emotions and challenges can be discussed (NMC, 2006). Despite NMC (2006) recommendations however, the utilisation of preceptorship support strategies in practice is limited, with its use across the NHS being fragmented and inconsistent. However the literature does demonstrate that preceptorship strategies can be very effective in supporting newly qualified nurses in successfully managing such transitions, with student nurses reporting that preceptorship facilitated easier transitions into clinical practice and helped them to negotiate better understandings of their new roles (Mooney, 2007). Whitehead's (2001; 2011) studies' findings led to the recommendations that newly qualified nurses must have access to preceptorship, clinical supervision and some form of full time support so that difficulties can be addressed swiftly and reduce the number of newly qualified nurses living too hastily without appropriate discussion the nursing profession. As Whitehead (2011) states, social support and peer interaction can help to address and alleviate fears and stress through nurses being able to access appropriate emotional support and guidance at any time (Mooney 2007).
A qualitative study by Jonsen et al. (2012) examined the impact that providing preceptorship support elicited upon nurses' successful transition into new practice, Jonsen et al. (2012) identified three key aspects, these being: preceptors; theory and practice; and reflection. Jonsen et al's (2012) findings revealed that student nurses found the availability of support through preceptorship facilitated positive working environments which promoted feelings of security and yet fostered enhanced confidence and greater clinical effectiveness. As Jonsen et al. (2012) state, preceptorship provides contexts in which nurses are able to reflect upon their clinical practice experiences, which provides an environment in which students are able to balance theory with practice and personal with professional values, which facilitates better practice and confidence.
In summary, this essay demonstrates that to ensure student nurses adapt and make effective transitions to the role of newly qualified nurse, vital support is needed to offer appropriate supportive working environments, which can help nurses to re-negotiate the theory-practice gap. NHS settings need to acknowledge, accept and address the unique and individual needs of newly qualified nurses so that strategies can be employed that can facilitate continued professional development and encourage nurses to discuss their actual fears, issues and needs. The provision of preceptors and supervisors is essential to enable newly qualified nurses to have access to contexts in which personal and professional values can also be discussed so that they are able to not simply assimilate dominant practices inherent in the NHS setting but to also question them. Such strategies can thus offer newly qualified nurses context in which to reflect upon such practice experiences so that they can make sense of their new roles and re-negotiate new identities. It is therefore recommended that nurse training must address the potential transitionary difficulties that newly qualified nurses can experience to better prepare individuals for the realities of professional practice. NHS health care contexts must also promote greater access to preceptorship for newly qualified nurses to cater to the specific needs of newly qualified nurses. It is anticipated that through this development and a universal shift to enabling newly qualified nurses access to support such as preceptorship, newly qualified nurses can act with greater confidence and feel more supported in their clinical practice.
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