Patricia Benner, R.N., Ph.D. FAAN
Copyright EducatingNurses.com, January 2019
The first nursing positions are bound to be formative for nurses. By “formative” I mean identity development as a nurse, skills, habits of thought and relational ways of being with patients and the healthcare team and more. Socialization messages are received from co-workers, preceptors, professional developers and supervisors. Experienced nurses and new nurses, themselves, are also deeply involved in their own formation and identity as a nurse, being and becoming the kind of nurse they want to be, now that they have graduated. Socialization provides outside information on how to be a nurse that is invaluable, but equally important are the commitments, concerns and aims that the new nurse, has in terms of learning to be a good nurse. By “good nurse” I mean being both clinically and ethically competent in one’s actual nursing practice.
It is helpful to distinguish between the external & internal forces of professional development. The external socialization & instructional influences of all members of the healthcare team combine with the internal self-efforts each nurse engages in forming him or herself. Formation of identity, habits of thought and ways of being a nurse develop when new nurses are confronted with the challenges of learning how to be a good nurse in specific clinical situations. Most clinical situations are under-determined (outcomes are not certain), and grasping the nature of a whole clinical situation is necessary for knowing how to proceed, and how to be with particular patients in particular situations (Benner, 2011; Benner, Sutphen, Leonard-Kahn & Day, 2009).
Preceptors and the whole healthcare team coach the new nurse on how to grasp what is required to address the changes in a patient’s clinical condition. Without the situated coaching of more experienced and knowledgeable nurses, the new graduate is left with limited resources to grasp and solve the new clinical situations that occur once they are performing as Registered Nurses. Patient safety, as well as the ability for the nurse clinician to learn and grow, are at risk if adequate situated clinical teaching is not available to the newly graduated nurse.
In this article, we look at both socialization and formation as sources for the self-defining commitment to become the new nurse aspires to be. The professional development provided by a new graduate residency programs offered for new graduates and nurses with less than a year of nursing experience at Providence Health Care facilities of Sacred Heart Medical Center & Children’s Hospital & Holy Family Hospital are influential in shaping the nurse’s habits of thought and bedside practice. We interviewed Lynn Stapleton, a Nurse Professional Development Specialist (NPDS) who assisted with the development of an RN Core Fundamentals Program, and a yearlong program that is offered to all Nurse Residents (RNs who completed their entry-level nursing education within one year of hire). Ms. Stapleton is employed by Providence Health Care (PHC); the Core Fundamental Residency Program she helped to create was developed by the Clinical Academy of the Providence St. Joseph Health System’s Nursing Institute (PSJH Clinical Academy). The PSJH Clinical Academy also developed several Transition into Practice (TIP) Programs, formal specialty practice nursing orientation programs that are offered to nurse residents and fellows (RNs with one or more years of nursing experience). The TIP programs contain unit specific information regarding patient care & processes encountered by nurses in those areas.
As Lynn Stapleton notes, the transition from nursing school to working as a “real” nurse is huge. We have been reviewing the demands of learning practical, clinical and all kinds of local knowledge (Geertz, 1983; Bourdieu, 1998) on a variety of units that have an array of specialty patients. Stapleton stays in touch with the inevitable challenges of being a new nurse in a complex hospital setting, but particularly the challenges experienced by the new graduate nurse. We follow Lynn Stapleton’s exemplary large RN Core Fundamental Residency program where she meets with each new graduate when they attend their initial class and follows them through the one-year program, which consists of 6 intentionally spaced, formal classes and individual meetings as requested. She greets the new graduate with her primary objective: “The first goal is for you to be mentally & physically healthy & happy through this first year of your nursing journey.” She then follows through with providing resources for hospital support services and meets individually with those who request to do so. Lynn works with unit nurse management, other NPD practitioners, and preceptors, when warranted, to assist the resident nurse through particular difficult transitions by creating clear, measurable goals for success. The centerpiece of the program is the situated coaching of clinical preceptors, who are both clinically astute, and equally good teachers.
New Graduate and Nurse Fellows Transition Programs
There are two new-hire transition tracks at PHC Hospitals in Spokane Washington; one for all newly graduated nurses, residents, and one for nurses who have worked more than a year in another clinical setting, i.e., fellows. The fellows, having worked in different facilities since graduating have a more tailored preceptor program designed for them which takes advantage of their experience, but also works on smoothing the difficulties that may have occurred in that first clinical position.
Preceptor Selection and Training
Unit nurse managers and assistant nurse managers pick clinical preceptors, based on their clinical expertise and willingness to train new staff. Each clinical unit preceptor receives training to work, support, and communicate with the new graduate. Preceptors are encouraged to understand that, ‘how a new graduate hears and receives feedback, may not be what the preceptor intends’. They provide multiple communication tools to assist with this experience and enhance their training relationship with the new graduate. This also lays the groundwork for understanding that sometimes a particular preceptor and new graduate may not be a good teaching-learning fit and a process is established so that when this relationship is not optimal, preceptees and their assigned preceptors may be changed without conflict or stigma. Changing preceptors and preceptees is normalized. Lynn Stapleton, who is not directly involved in the particular clinical units, plays a mediating and supportive role in helping a preceptor and new graduate make this change in preceptors.
One goal of the Preceptor Training Program is to teach preceptors how to clinically teach and learn, emphasizing aspects of Adult Learning Theory (Knowles, et al., 2015, 8th Ed.). Adult Learning Theory emphasizes that adults are always connecting with what they already know, both formal textbook and experiential clinical learning. This is emphasized for the Fellows who have had clinical experience in another setting. A phrase used often by Fellow new hires during the precepted time is, “At my other hospital we used to do it another way”. This can be interpreted by the preceptor as, “At Hospital Wonderful we used to do it this a different way which is much better.” Stapleton re-translates this phrase from experienced new hires as an attempt to connect the current clinical practice with past experience as an adult learning approach to connect current learning with past learning. This re-framing from a negative contrast with the former hospital to an adult learning technique, takes away the judgmental feel of comparisons with past hospital experience. In future installments on clinical teaching and learning we will present how a number of clinical preceptors understand and perform their role as preceptors. Interviews with these preceptors emphasize challenges and successes with each preceptor’s situated coaching. Part of the focus will be on the local knowledge (Geertz, 1983) required in learning to function in each new health care institution and with any clinical population.
Transition Residency for Newly Graduated Nurses and Newly Hired, Less-Experienced Fellows as a Resource for Retention
This system-wide Providence New Graduate Transition Program is highly successful in retraining their newly graduate nurses. Stapleton points out that of the 345 nurses who entered the Core Fundamentals Residency Program since it started in April 2016, only 31 nurses left their hospital position within a year, which is a turnover rate of 8.9%. This percentage is well below the 28.3% first-year turnover rate reported by Nursing Solutions Inc. in 2018. This is a phenomenal retention rate for new graduate nurses. Since orientation is so expensive, this retention rate more than pays for the Transition Program.
From the first class and throughout the program, Stapleton’s emphasis is the use of shared clinical learning examples in the form of first-person experience near narratives by having each participant answer a content-guided question. This facilitates peer-to-peer open discussions and creates a shared understanding that all the new nurses are encountering both similar successes and challenges. This discussion format allows them to learn from each other and develop their abilities to handle clinical situations which enhance their bedside practice. The stories of personal clinical learning carry a narrative record of the learning and growing of the newly graduated nurse’s development. These first-person stories of real situations help others in his or her cohort understand that their own challenges are common, shared, and not just unique to one new graduate. As Stapleton points out, the first-person real narratives help the new graduates bond with each other. The bonding within a cohort of newly graduated residents forms an informal support group among peers that lasts throughout the program and even afterward.
Emphasizing “Presence” and “Voice”
In our second Interview Segment (Part II), Lynn Stapleton explains her central goal in working with each new graduate and Fellow cohort member is to learn how to be present with patients and to develop their voice as a nurse. By ‘being present’ she explains that she means active listening, an unhurried attentive being with a patient and their illness and treatment experience. I want to highlight this goal of keeping patient experience and patient connection as a front-line teaching and learning goal of Stapleton’s New Graduate Residency Program. Upon work-entry, the hospital as a learning institution, with compassion and good patient experience as goals, has the best and first opportunity to exemplify and teach being present, attentive, and responsive to patient & family concerns, fears, and clinical needs. Presence also enhances the possibility of recognizing the nature of the whole clinical situation which is at the heart of good clinical reasoning. Benner, P. (July 30, 2018) Situated Clinical Teaching and Learning. Retrieved from https://www.educatingnurses.com/situated-clinical-teaching-learning/ The beginning of one’s orientation to a hospital culture is a prime moment to teach compassionate care and work civility.
By “voice” Stapleton means the ability to speak up and advocate for patients, but also emphasizes the importance of knowing when to be quiet with active listening in emotional, difficult, or volatile situations. Learning when and when not to speak in a highly charged clinical situation is a complex and challenging clinical learning experience that the new graduate nurse has to learn first-hand in a work setting. It’s more difficult when the work environment neglects direct support, debriefings, or feedback on performance. In many clinical settings, feedback on one’s use of voice may be unnoticed, and they may not give feedback. Lynn Stapleton uses the first-person experience near narratives from the new graduates to point out both presence and voice. I think every new graduate and new-hire orientation program would do well to plan and implement ways of teaching improved patient-nurse presence and healthcare team voice. We will continue with this series on front-line clinical teaching and learning in our next installments.
In this series, it is never far from our thoughts about how difficult it is to translate “knowing that, and why” into actually “knowing how, and when.” The complexity of clinical or practice knowledge development in any practice field (Bourdieu, 1998, pp5-91) (such as nursing, teaching, medicine, law, social work and so on) requires being able to connect or create a dialogue between the particular clinical situation and the generalizations that we most often emphasize as teachers and learners. Clinical learning in any field requires creating an understanding of the particular in relation to the general, with equal attention and respect for both. This conversation on the particular in relation to the general will continue in this series on clinical teaching and learning.
Benner, P. (2011) “Formation in professional education: An examination of the relationship between theories of meaning and theories of the self.” Journal of Medicine and Philosophy, 36: 342–353, 2011
Benner, P., Sutphen, M., Leonard-Kahn, V., Day, L., (2009) Educating Nurses: A Call for Radical Transformation. San Francisco, CA: Jossey-Bass.
Bourdieu, P. (1998) Practical Reason On the theory of Action. Stanford, CA: Stanford University Press. (See pages 75-91).
Geertz, C. (1983) Local Knowledge, Further Essays in Interpretive Anthropology. New York: Basic Books
Knowles, M. Holton, E.F.III, Swanson, R.A. (2015, 8th edition) The Adult Learner. New York: Routledge.