Transitions: Adjusting to working life

May 2016   Comments

Novice RNs and leaders in the profession share their thoughts on the challenges and available supports for graduates entering the workforce

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This year, thousands of Canadian students will graduate with nursing degrees and enter the working world, where heavy caseloads and fast-paced practice environments can come as a shock to them. While hospitals and nursing schools use mentorships and clinical placements to prepare students for the workplace, new graduates form their own support networks, often keeping in touch with each other through social media. Overall, new graduates and nursing leaders agree that the challenges of transition can be surmounted.

“I think having a good support group of friends and keeping in touch with your mentors helps a lot,” says Tonie Castro, who graduated in December 2015 from Vancouver’s Langara College and now works at the Burnaby Centre for Mental Health and Addiction. “The first six months are the hardest, and I think I’m doing well with the transition because of my support group.”

Finding a full-time job
For many nursing graduates, finding work is the first challenge.

“For the last three years, it’s been very difficult to get a permanent position unless you go into remote areas or live in some areas of the Atlantic provinces,” says Linda Silas, president of the Canadian Federation of Nurses Unions.

Catherine Polvi graduated from Dalhousie University in May 2015. The QEII Health Sciences Centre in Halifax hired her in January of that year, and she started her job in the hematology and oncology unit of the Victoria General site four days after graduation.

“I got my first choice of job and all my friends got their first choice of jobs. Everyone I know got pretty much their dream job,” she says.

But Bryce Boynton, who is studying at the University of Saskatchewan and is president of the Canadian Nursing Students’ Association, says most of the new grads he knows in Saskatchewan get a casual position, hoping to work their way into one that’s full time.

For Castro, impressing her manager during her final preceptorship led to a job at the Burnaby Centre. The position fits with her goal of working with marginalized populations, but she doesn’t yet have full-time hours and this wasn’t her first choice of practice settings.

“I wanted to get a job in public health, but that field can be tough for new graduates to break into,” Castro says. “I’m glad I am able to work in the community in the field of mental health and addictions, and so far I’m enjoying it.”

Finding their feet
Nurses entering practice can find the caseload and the pace of work overwhelming, says Lori Lamont, vice-president of interprofessional practice and chief nursing officer of the Winnipeg Regional Health Authority — it hires about 200 new nursing graduates per year. New graduates go from having a caseload of one or two patients as students to anywhere from four to eight patients as RNs. As well, because of shortened hospital stays, today’s patients are typically more acutely ill than those of 20 years ago.

Clinical placements during nursing school can help ease the transition for new nurses, says Lamont, who is also president of the Academy of Canadian Executive Nurses. “Locally, both Red River College and the University of Manitoba have a senior practicum in the last year of undergrad,” she says. “Most grads get a job where they had their practicum. That allows them to be in a familiar environment so they’re not dealing with so much that is new.”

According to Dalhousie University nursing professor and researcher Sheri Price, all Canadian hospitals offer some kind of orientation program for new nurses. Some offer further support during the first year after graduation, including the IWK Health Centre, a children’s hospital in Halifax.

“We created a position for a recent graduate who coordinates education sessions for new grads three to four times a year, to bring them together so they can support each other’s learning and transition to practice. We ask the new graduates to identify their learning needs, and the sessions focus on meeting their needs,” Price says. “We created a Facebook group and a Twitter account so they can stay connected, share stories as to what’s been helpful to them and reach out to one another.”

Some nursing leaders believe new graduates benefit a great deal from transition programs and that they should be taken further. Cynthia Baker, executive director of the Canadian Association of Schools of Nursing, says a progressive in-service orientation program of six to 12 months — similar to a residency program — should be available for new nurses across Canada.

“In medicine, they do a long residency before they enter any type of practice as working independently. We don’t see that in nursing,” Silas comments. “From 2002 to 2009, we established great mentoring programs across the country where we took experienced nurses and matched them up with new grads. The evaluations were great. Then the budgets of hospitals were cut and all the mentoring programs, except in Ontario, have disappeared.”

Taking it all on
Although Polvi completed a clinical placement in the unit that then became her workplace, she encountered a new reality once on the job. “Your patients are your responsibility and you have to own everything you do,” she says. “And then going home and worrying about everything you did — the stress of that was definitely hard.”

Castro says it’s important to trust yourself and to draw on the decision-making skills learned in nursing school. “It’s about having the confidence to make the judgment calls,” she adds.

Nursing students on clinical placements often get sidelined when patients start rapidly deteriorating, Lamont says. While this approach is understandable, it fails to prepare students to cope with such situations after graduation. To fill this clinical gap, nursing schools are teaching them to make judgment calls in critical situations with high-tech simulation labs in which a computerized mannequin acts as the patient.

“They’re sophisticated,” says Baker, who started a high-fidelity simulation lab at Queen’s University in 2005 when she was director of the school of nursing. “You can ‘kill’ the dummy if you do something wrong, and you’ll never forget what clinical error you made. I think these labs are effective in helping prepare new graduates for clinical practice situations.”

Price and her colleagues are looking at ways in which computer games can be used to develop communication skills, by putting students in virtual situations where they must face challenging interactions with patients, colleagues or managers. “Many students are already gaming,” she says, “so we want to explore how we can use serious games to benefit their professional development.”

Dealing with stress
Working on a locked unit with patients who have a mental illness can be stressful, Castro says. “Clients can get very agitated. If they are craving drugs or a smoke, it’s a nurse they will talk to….Sometimes they swear at you. And there’s a risk of aggression,” she says. “It can be draining.”

She tries to manage the stress by reaching out for support to other nurses on the unit and pacing herself. She advises: “Learn to take your breaks on time. Learn your limits. Take time to meditate throughout the day.”

Lamont says it’s important for managers to take the time to debrief a new nurse after a complex situation and to sensitize other nurses to the challenges the new nurse faces in adjusting to working life. “Many of our new nurses experience disrespectful or bullying behaviour in the workplace. Sometimes, we as experienced nurses give feedback that undermines their confidence and makes them feel that they’re never going to cut it.”

A supportive work environment is a big factor in easing the transition. “I took a patient down to the ICU recently and someone came down with me and said, ‘I’ll stay with you, and I’ll walk you through it and tell you what to do,’” says Polvi. “If a patient isn’t doing well, everyone just jumps on board.”

Building a career
In 2009, Price began a five-year longitudinal study that followed 12 students from the time they entered nursing school to one year after graduation. She was surprised to discover the extent to which millennial nurses are focused on career development and planning. “They want someone to ask them where they want to be in a year, five years, ten years, and help them map that out.”

She says nursing professors, managers and mentors can help students and new graduates by giving them more information about the types of extra courses and experience they will need to move into other specialties and areas of practice.

Polvi has just completed a chemotherapy course and now wants to pursue oncology certification through CNA. “I’m craving more knowledge,” she says. “Sometimes we don’t have time to research each patient’s condition thoroughly because we’re too busy caring for them. I definitely feel like I want to do more education.”

Whether existing transition programs for new nurses are sufficient remains a matter of debate, but Price says this generation is well informed, well prepared and committed to patient care. “All the students I spoke to said the transition shock wasn’t as bad as they thought it would be, and they were able to identify additional supports and resources that would be helpful to them.”

Kate Jaimet

Kate Jaimet is a freelance journalist in Ottawa.

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