Honeymoon Phase

During the honeymoon phase, everything is just as the new graduate imagined. The new nurse is in orientation with former school friends or other new graduates who often share similarities. Many novice nurses in this phase are heard making the following comments: “Just think; now I’ll get paid for making all those beds” and “I’m so glad I chose nursing; I will be a part of changing the future of health care.”

Shock (Rejection) Phase

Then orientation is over, and the novice nurse begins work on his or her assigned unit. This nurse receives daily assignments and begins the tasks. “But wait. I’ve only observed other nurses hanging blood. Where is my instructor?” Now the shock or rejection phase comes into play. The nurse comes into contact with conflicting viewpoints and different ways of performing skills, but lacks the security of having an expert available to explain uncertain or gray areas. “As Registered Nurses, they found they have to ‘think on their feet’ without the ‘comfort blanket’ of student status” (Standing, 2007). The security of saying, “I am just the student nurse,” is no longer valid. During this phase, the novice nurse may be frightened or react by forming a hard, cold shell around himself or herself. Vague feelings of discomfort are experienced, and the inexperienced nurse often wonders whether the other nurses care about the patients. After going home from a shift, the new nurse may experience feelings of rejection and a sense of lack of accomplishment. The novice nurse may reject the new environment and have a preoccupation with the past when he or she was in school. A need to contact former instructors, call schoolmates, or visit the nursing school may occur. Others may reject their school values and adopt the values of the organization. In this way, they may experience less conflict (Kramer, 1974); however, there are drawbacks to this approach as well.

During this phase, Kramer (1974) suggests that novice nurses must ask themselves two important questions:

Dealing with the shock phase can be approached in many different ways. Some common approaches for dealing with it are reviewed in the following sections. After that, each nurse must decide which method best allows the previous two questions to be answered.

Compassion Fatigue

Not to be confused with burnout or transference, compassion fatigue is the gradual decline of compassion over time as a result of caregivers being exposed to events that have traumatized their patients (Figley, 2001). Even experienced nurses, who commonly have a great deal of empathy working in environments where patients suffer trauma, may develop a reaction in which they have a decrease in compassion. Exposure to traumatic events experienced by their patients may result in compassion fatigue. Nurses who work in emotionally charged environments, such as hospice, emergency departments, and mental health settings, are likely to experience this reaction. Intensive ongoing losses such as those in oncology care make nurses vulnerable to burnout and compassion fatigue (Potter et al, 2010). The balance between caring too much or too little is difficult to achieve (Lester, 2010). Nursing students are also at risk for compassion fatigue and need to identify their stress triggers (Sheppard, 2011). The compassion fatigue process is depicted in Figure 24-1.

Recovery Phase

The return of humor usually is the first sign of the recovery phase. The novice nurse begins to understand the new culture to a certain degree. There is less tension and anxiety, and healing begins. The nurse in this phase may comment, “I’ll hang that blood, and I’ll bet I can infuse it before 8 hours this time.”

Resolution Phase

The resolution phase is the result of the shock phase combined with the novice nurse’s ability to adjust to the new environment. If the nurse is able to positively work through the rejection phase, he or she grows more fully as a person and a professional nurse during the resolution phase. Work expectations are more easily met, and the nurse will have developed the ability to elicit change.

Most novice nurses experience each phase of reality shock (honeymoon, shock or rejection, recovery, and resolution); however, the degree of shock is individualized. For example, the new graduates who complete their clinical rotation during school in the same institution as they choose to begin their career may suffer reality shock to a much lesser degree because they already may be familiar with the environment, staff, and overall personality of the nursing unit. However, many students choose another institution for various reasons, such as better hours, better pay, or less travel time to work. Nurses who choose to work in an institution different from the one in which they worked as student nurses may experience a higher degree of shock. This does not imply that all nurses should work in the institution where they received their clinical educational experience. The staff in the institution where novice nurses were educated may continue to see them as only “student nurses,” which simply presents another barrier for novice nurses to overcome.

Zerwekh and Claborn (2009) suggest completing a reality shock inventory to make nurses more aware of how they feel about themselves and the situation at present. The higher the score, the better the attitude. It might be helpful to take the test at different times throughout one’s career or when trying to decide whether a career change would be advantageous (Box 24-1).

Partial-Task versus Whole-Task System

This type of health care, in which different members of the health care team divide the patient care into parts, is termed the partial-task system and only requires partial knowledge (Kramer, 1974). For instance, one nurse may be assigned to administer all medications, whereas another may be assigned to dressing changes. The nursing assistant aids with personal hygiene and grooming; the physical therapist provides range-of-motion exercises, and the respiratory therapist teaches pulmonary hygiene techniques. There are many other nursing care delivery models in which the role of the RN varies considerably. The partial-task system just described is also congruent with the model known as “functional nursing,” which places a high emphasis on completion of tasks. It is an efficient method when working with large numbers of patients, but the nurse cannot provide holistic care within such a system (Huber, 2010). With functional nursing and the partial-task system, the nurse is seen as only part of the care picture, but the RN is the central organizer and responsible for follow-through on all care given by other members. This type of system is popular because fewer professional staff members are required, and it is frequently used on the evening and night shifts when staffing is considerably less. This type of partial-task system encourages loyalty to the organization because it forces the nurse to focus on task completion and productivity. The nurse ensures that all tasks are carried out, but is not the sole provider of care. A simple checkmark often assesses quality, with initials being placed by completed tasks (Box 24-2).

BOX 24-2   WHOLE-TASK AND PARTIAL-TASK CHECKLIST

WHOLE-TASK CHECKLIST		PARTIAL-TASK CHECKLIST
(Completed by same nurse)		(Completed by different members of the health care team)
Initials	Task	Initials	Task
TN	Nursing history	SJ	Nursing history
TN	Nursing assessment	TN	Nursing assessment
TN	Patient education	BC	Patient education
TN	Medication teaching	CS	Medication teaching
TN	Bed made	CS	Bed made
TN	Intake and output recorded	SJ	Intake and output recorded
TN	Dressing changed	SJ	Dressing changed
TN	IV fluids hung	CS	IV fluids hung
TN	Patient turned	BC	Patient turned

Most novice nurses are more comfortable with the whole-task system because it is more consistent with what they were taught in school. The whole-task system requires complete knowledge and encourages loyalty to the profession. The nurse provides total patient care, which incorporates physical, emotional, spiritual, and cultural components. The model of nursing care consistent with the whole-task system is primary nursing, in which the nurse is responsible for all the needs of the patient (Huber, 2010). This model provides increased satisfaction for the patient and the nurse. However, because of the need to use an increasing number of lower-salaried employees and the shortage of RNs, few institutions continue to use this model.

Evaluation Methods

Another inconsistency between the school and work environment is the means of evaluation (Kramer, 1974). The school environment evaluates care from the

“correct step” aspect, whereas the evaluation phase in the work environment is based on whether components of care were completed according to established policies and procedures. Were all the steps carried out in a logical, correct, and efficient way? This is exemplified in Case Study 24-2.

Think back to your first days in the nursing skills course. Can you remember the hours of practice you spent in learning the Six Rights of medication administration and technique of parenteral medication administration? Remember the stress you felt when the instructor observed you drawing up and administering your first intravenous (IV) push medication? How much error did the instructor allow? Probably not much. This is not to say that you should become lax in your tolerance for error. For example, it is never acceptable to have errors in the Six Rights of Medication Administration. You must and will develop your own system and quality check for performing nursing care. Nursing texts often list supplies followed by a flow diagram for procedures in which each step is listed. Let us go back to the resuscitation scenario: even basic and advanced life support courses focus on algorithms that direct, step by step, the care of the patient. Always remember that patient safety comes first.

The transition from student to professional nurse is difficult, and changes in the health care environment have only added to the strain. Socialization of the novice nurse is key to his or her ability to transition or just “survive” at the clinical level (Mooney, 2007). Often new nurses are greeted with open hostility rather than being welcomed (Adler, 2009). Nursing administrators may not support the novices’ need to learn and may expect them to perform at the same level as experienced nurses. Unfortunately, the novice nurse may become bewildered and discouraged.