An Exploratory Study of the Orientation Needs of Experienced Nurses

Abstract

The orientation period creates a context for a nurse’s relationship with her employer, and can adversely affect attrition rates. While the orientation needs of novice nurses have been detailed, little is known about what might help those with prior experience. Hence, the goal of this study was to explore whether the orientation needs of seasoned nurses are similar to or unique from novice nurses. Over a six month period, we used two intensive qualitative methodologies (daily journaling and focus groups) to study three experienced nurses. A tri-phased model of orientation emerged, with learning and support issues unique to experienced nurses identified. Results suggest that orientation programs for experienced nurses should utilize specific educational strategies and content to promote engagement in a new position.

Introduction

Often, from the moment of hire, the work environment shapes a nurse’s attitude and satisfaction (Cavanagh & Coffin, 1992), with some experts suggesting that adequate orientation sets the tone for a nurse’s intent to continue in a job. According to Keefe, (2007) the first 30 days of a new job are so critical to retention that inadequate programs can result in a different type of “burnout” where nurses leave a position before they have even acclimated to it. While much attention has been given to the needs of novice nurses during this early phase of their work life, little information is available on how nurses with prior experience may respond to job transitions.

Orientation Challenges For Experienced Nurses

For all nurses, the orientation period/process can be both thrilling and threatening. There are many suggestions in the literature on how to educate and support the novice nurse during orientation, with the perhaps unspoken assumption that experienced nurses will have less difficulty.

Studies do show that nurses with more experience differ significantly from newer nurses in terms of vocational strain and coping (Santos & Cox, 2000). As noted by Bartz (1999): “Continuing professional education traditionally focuses either on the orientation of novices into a profession, or ongoing in-service education for experienced professionals.” (p. 212). To learn more about the needs of nurses with previous experience, she studied ten nurses orienting to a specialty setting, and concluded that these nurses adopted varied methods of learning as they identified deficits. Domrose (2002) says:

Although most mentoring programs focus on new grads, the profession needs to rethink the value of mentoring for nurses at all levels in their career, when they start a new job, enter a new dept…. Even experienced nurses from other hospitals may find themselves in need of someone to make them feel welcome and help them navigate the system.

For experienced nurses, the possibilities of a new position are often tempered by fears of inadequacy. Having worked previously, there is a better ability to realistically appraise and understanding what is to come in the new job, while adjusting to a change in both personal and professional routine. If his/her departure from the previous job was acrimonious, feelings of resentment, grief, and anger may persist. (See Table One) For these reasons, researchers (Holmes & Rahe, 1967) list changing a job as a significant life stressor (Table 1).

Table 1.

Unique orientation needs of experienced nurses

Situation	Consequence
Prior work history	More realistic appraisal of new job and one or more standard(s) of reference
Previous experience in a specialty area of nursing	More flexible attitude toward learning additional specialized skills
Imposter phenomenon	As “experienced” nurse is expected to adapt quicker to new job
Significant life change	As established worker, changing jobs is a life event that requires adaptation
Context of transition	New job may be a consequence of trauma at previous job, professional advance, or secondary to relocation, divorce, etc. which can lead to grieving or additional stress

Relatively few organizations have looked at how the educational and support needs of experienced nurses might present differently during orientation. While experienced nurses beginning a new job may have more confidence in their abilities, they may also be challenged by the assumption that their adjustment will be easier because they have worked as a nurse before and can “hit the ground running.” Therefore, exploration of their response to the orientation process is important. In their discussion of recruiting and retaining experienced nurses, Mion et al, (2006) offer many innovative strategies for keeping nurses in their positions, but overlook the importance of the orientation period, when many critical decisions about continuing in a job are made.

An experienced nurse must inevitably assume a novice role during job changes, which can create difficulties. Equally challenging is failure to allow the orienting expert practitioner to be a novice in appropriate ways.Clance and Imes (1978) developed the term “imposter phenomenon” (IP) to describe a shared perception of fears among women in high level professions. Their study reports that despite their achievements, these women secretly feared that others would discover they were not as competent as the appeared. Feeling a need to present oneself as an “expert” regardless of one’s status as a novice or experienced nurse can foster a sense of IP and create reluctance to admit a need for further education and/or support.

Experienced nurses are likely to fall within this mindset.

Forbes & Jessup (2004) describe the “unexpectedly powerful and potentially ego-deflating” situation of a experienced nurse who was transitioning into an advanced practice role, and the many challenges experienced in assuming a new professional role and responsibilities. They say, “Rather than set unrealistic expectations that then elicit irrational angst, the expert to novice should instead acknowledge his or her lack of command in the domain…” (p. 184). This acknowledgment of novice status should not reflect on abilities or professionalism, but rather a new circumstance in life.

Study Goal

The goal of this pilot study was to describe the orientation process for three experienced nurses who were beginning new positions as diabetes case managers at a large academic medical center.

Method

Participants

To address the study goal, the participants were monitored closely throughout their six month orientation period. The work histories of these nurses varied greatly. Nurse A was in her forties and had worked for 15 years in public health where she had been a case manager. She had an Associate Degree in Nursing and had gone through three previous job transitions. Nurse B was in her twenties and had worked for four years in acute care inpatient setting. She had transitioned twice before and was currently enrolled in classes toward her Bachelor of Nursing degree. Nurse C, who had a Bachelor’s Degree in Nursing, was in her thirties and had been employed as a middle manager in hospital inpatient unit. This was her fourth job transition. All three nurses had functioned in a specialty area of nursing and/or a supervisory positions, so they qualified as both experienced and expert nurses.

Two of the nurses were Caucasian and one Hispanic. All consented to journal daily and participate in a focus group evaluation of their adjustment to the new position.

Design

Throughout the three-month period, nurses kept a daily professional journal which focused broadly on their responses to the new job situation. The instructions they were given as they used the journal was to record any thoughts or feelings they felt were relevant to their response to the educational components of the orientation process, and specific needs for support.

At the end of the three month orientation period, a focus group was held to further explore the concept of transitioning into a new position. The facilitator of the focus group was an experienced researcher who had previously conducted many similar groups. The prompts used to generate discussion were decided upon by the facilitator and clinical supervisor of the nurses. They included:

• What was it like to begin this new job?

• How did you feel about the educational content and presentation?

• What needs did you have during the orientation process that were and were not met?

The focus group, which lasted approximately 90 minutes, was tape recorded. After the interview concluded, the tape was transcribed, cleaned, and independently coded by each of the nurses, the facilitator, and the clinical supervisor.

Data Analysis

To evaluate the data, the focus group transcript was reviewed using an iterative process to identify salient metathemes related to orientation. Selected journal entries were used to confirm or contradict themes as appropriate. Other statements from the focus group or journals were “data” that enriched the thematic analysis. Once the point of saturation was reached, i.e. consensus between all coders on interpretation, findings were used to create a model which would describe the orientation process these nurses experienced.

Results

Three themes emerged from the analysis, suggesting that experienced nurses transition in a fluid manner. These themes are portrayed in the Experienced Nurse Transition Process (ENTP) (Figure 1).

Figure One.

Experienced Nurse Transition Process

Theme One: Assessing Expectations

When nurses were asked how it felt to “live” the experience of transitioning into a new job, their responses about the initial days and weeks of orientation revealed they felt conflicted and uncertain, often questioning their decision to accept the position and wondering if their expectations were realistic. Comparisons with previous positions were made in an effort to validate or refute these perceptions. Confronted with a wealth of new material to learn and master within a short period, they found themselves returning to a place of doubt frequently.

While a variety of responses to the first few weeks of orientation were reported, most were weighted toward stressfulness. Anxiety, nervousness, and even somatic responses to the new job responsibilities were reported, tempered by excitement over the possibilities the change offered. Comments include, “ So I really just told myself, so I wasn’t disappointed or had anything unrealistic expected of me, that I would just go in, take it as it came, and you know, try to adapt to it.” (Nurse B)“I was nervous about meeting the other two people. I wasn’t sure how that was going to go.” (Nurse C)

Specific anxieties related to the ability to perform the new job responsibilities, the nature of new coworkers, conflict, and the uncertainty of the job expectations. “I’m afraid at failing at this. (Nurse A) “I feel like a blithering idiot. (Nurse C)

In the focus group, these feelings were elaborated,

I would say my anxiety was higher because I was worried about what I was going to be asked to do and things like that. ”…

No wonder we were going crazy. Someone comes in and has their PhD in counseling and does it [MI] wonderfully and I come in and OK I’ve been doing this for two weeks and I’m a nurse. They have been practicing for years and years about talking to people like that and I haven’t. I am so uncertain I don’t have anything to be confident about. (Nurse B)

Tied in with the excitement of possibilities was the statement by all three nurses that some aspect of the new job had been conceptualized as “ideal” during the interview and pre-hire process. In their journals, all three nurses questioned: "…did I make the right decision?" " …the grass did look greener on the other side." (Nurse B) They quickly began to question whether they would be able to do the job, what the job entailed, and how they might know when they were doing the job correctly. For these experienced nurses, it was somewhat shocking to find themselves in the position of “novice” as well as learner, and the concept of being intensively evaluated as they learned the MI process was intimidating.

Theme Two: Realistic Appraisal

These nurses quickly moved into a phase of confronting challenges. They had enough understanding of the new job to have been realistic in their appraisals, and could answer some of their earlier questions and doubts in both positive and negative ways. A point came where they transitioned into a place of different challenges.

Concern about performance led nurses to struggle to balance what they knew with what they were expected to learn, causing a paradigm shift. Given their past experience in nursing, they were able to identify knowledge deficits as well as their own abilities to handle them. Although the early orientation period had officially “ended,” one nurse said:

I’m still nervous about it [MI].I’m still not real comfortable with it, but I’m still waiting for the morning when I will wake up and it will be comfortable. Just like making that transition of being on your own and having your own group of patients and feeling confident and competent. (Nurse A)

Performance anxiety was exacerbated by the absence of measurable outcomes and a perceived inability to practice or prepare for demonstrations of new skills. At the same time, nurses reflected on possible ways their own knowledge might allay concerns. “I received some positive feedback from other members of the team and it felt good.” (Nurse A)

The continued connection between emotions about their new position and physical health was apparent to the nurses.

It is Sunday night and I am already feeling anxious over this weeks classes. I feel like an old dog learning new tricks….I am losing sleep and having nightmares, I get so nauseous preparing for these sessions… I was forced to come out of my shell faster than other jobs but I think I grew from that. (Nurse C)

She went on to note: “I feel like I’m becoming more comfortable … I have learned how to manage my own discomfort.”

Despite their concerns, during this time, they were able to draw on past successes to persevere. A nurse commented in the focus group:“I’m a nurse. I don’t give up.” (Nurse C)

Theme Three: Acceptance

In spite of the concerns each nurse expressed, once their contact with patients began, their confidence grew and they began to recognize their abilities to meet the requirements of the new job. Comments such as: “Everyday I feel a little more confident about my role” (Nurse A) and “I can be successful at this because I was successful at my previous position.” (Nurse C) illustrate their adjustment. However, a degree of uncertainty and discomfort persisted, perhaps because nurses were still comparing this new position to previous ones. In the focus group, a participant discussed her uncertainty about knowing when she would be competent to do the job: “In nursing, you have measurable outcomes. You either get the tube in the right hole or you don’t. It’s either black or white”. (Nurse B)

Nurses knew that if they could discuss their feelings with peer clinicians, it would have been helpful. As described in the focus group:

I think if we had the opportunity to talk to other nurses who were doing this job and they could set some kind of timeline like you are going to feel like crap, you aren’t going to know what you are doing at all, and it’s going to take at least six months to feel comfortable. (Nurse C)

At the end of orientation, nurses reflected back and had awareness of professional and personal growth. “I find myself being a little bit more confident and friendly…” (Nurse C)

“I don’t have that feeling like I did at my other jobs where you are the new person on the block so we are going to dump all the junk work on you.” (Nurse B)

These experienced nurses sorted through how the new skills they had learned and the paradigm shift in patient interactions applied to their previous work experiences.

With time, nurses were able to see how their newly acquired MI skills would help patients and promote better care.

I’m not saying I never had deeper conversations, but knowing that you are not just talking about the situation and understanding and being empathetic, you are trying to get somebody to change their behavior…….being their advocate, getting on their doctor’s case….It’s trying to get them to make that long behavior change, so it’s a different kind of conversation. (Nurse C)

Once they could see how their new skills would better the health of patients, they felt validated. One nurse recalled finally receiving answers to her initial questions:

Then all the lectures started and it’s like, wait a minute, I don’t even know how this is going to fit into a visit. How is all this relevant? How do you do all this and see a patient? It was like show me how this actually fits into a clinical session, what am I actually doing? (Nurse C)

Limitations

Although a small sample size is typical in qualitative research, our nurses represented an elite group who were given the time to thoroughly document and discuss their experiences, which may have introduced a therapeutic benefit and bias. Additionally, these nurses would be assuming a specialized role similar to that of an ICU nurse, OR nurse, or others whose orientation period includes training in special skills.

Discussion

Valuable insights about the needs of experienced nurses emerged from the intense and varied sources of data collection (i.e. daily journaling and focus group), and suggest helpful strategies for the orientation process. It was interesting to note that although each of the nurses had functioned previously in expert and perhaps more demanding roles, their adjustment was still marked by doubt and anxiety.

Whereas a novice nurse enters a position with a certain set of expectations and anxieties based on “what might be,” experienced nurses had a work history that shaped their expectations and needs from the beginning, and entered the orientation with prior experience being oriented to and functioning in diverse nursing positions. While some of their responses to orientation were similar to those of novice nurses, the results of our study suggest important differences.

These nurses, with a rich work history similar to most previously employed nurses, went through a process more like transitioning than orienting. Their past history positioned them to make both realistic appraisals of external circumstances and be more flexible in learning new skills, but also have internal expectations that may have been higher than a novice.

While anxiety about the ability to perform a new job is common, these experienced nurses were more able to obtain confidence from past successes and utilize peers as a support system. The experienced nurses were less likely to identify a lack of leadership or acceptance and respect by coworkers as an issue during orientation, and did not cite a lack of preceptors as problematic. On the contrary, they seemed to fill this role for each other. They did, however, struggle with having to assume a novice role, although recognizing they all felt the same validated their abilities.

At each stage of the transition process, nurses identified resources which helped them continue to their forward momentum in transitioning. During the assessing phase, team building and informal meetings as well as a welcome dinner and other leisure activities helped create a sense of togetherness. In the appraising phase, receiving input from other nurses on the use of MI helped answer questions, and moving into specific content areas helped them understand more about the job. By the time of the acceptance phase, opportunities to apply new skills to patients in a real clinical situation and see the benefits helped.

Throughout, the nurses considered each other their best coping strategy. They saw it as important to be cohesive as a group, if only to validate their individual perceptions. When there was no way to know if progress was being made, the nurses turned to each other. One nurse said in a focus group and in her journal:

You really rely on the other person to say, “I’ve really seen you improve or I’ve really seen you grow. You rely on your co-workers or evaluators because it’s hard to say. (Nurse C)

The nurses came to recognize similarities in what each was experiencing, and used this to recognize that even though they were experienced nurses, it was “normal” to have questions and doubts. Nurse C said, “We share the same experiences,” and “I would advise others to rely on [your] co-workers, because that is what we have done. A lot of phone calls and emails back and forth.”

Conclusions

Although further research can provide more generalizable information, the results of this study nonetheless offer insights which can help shape the recruitment and retention of experienced nurses. In the context of orientation, the “one size fits all” approach does not work; tailoring parts of orientation to meet the specific emotional needs of nurses who are transitioning in their orientation rather than beginning from scratch may improve retention. Nurses who are orienting to advanced practice roles or novel specialty roles that may require learning a completely new skill set are likely to require even more support.

Specific considerations can facilitate a successful transition for experienced nurses (Table 2).

Table 2.

Tailoring orientation programs to meet the educational needs of experienced nurses

Phase One: Assessing Expectations	Phase Two: Realistic Appraisal	Phase Three: Adjusting
Ongoing dialogue about perceptions and expectations vs. reality Frequent check-ins to evaluate status Provide as much concrete information as possible Encourage opportunities for dialogue among experienced nurses to prevent unrealized expectations. Understanding the specifics of the role and responsibility expected of them is meaningful context for experienced nurses. Expect conflicts earlier in orientation process Nonjudgmental approach to criticism or complaints about orientation Recognize anxieties and doubts Don’t assume confidence or self assurance Build on past experiences Example: “You’ve done this kind of thing before. What worked for you?” might tap on inner strengths and share valuable insights.	Adjust learning program Allow him/her to progress at a self identified comfortable pace Encourage and respond to self assessments Have experienced nurses identify their own learning needs and evaluate their own performance Solicit and provide ongoing feedback about job satisfaction and expectations Asking experienced nurses to rate their current satisfaction with the transition process on a scale of 1–10 (10 being most satisfied) Encourage experienced nurses to discuss anxieties, concerns, etc. separately from novice nurses, and frame their concerns as normative. Avoid comments that could be interpreted as reflecting negatively on the nurse’s competence.	Discuss clinical applicability and relevance of new position Contact with another experienced clinical mentor/guide Allow experienced nurses to form their own support group Can convey concerns or requests back to supervisors may permit further honesty and understanding Journaling Allows nurse to monitor progress and encourages self reflection (Pennebaker, 1993). Writing is a good strategy for stress management

Little attention has been paid to the “experienced” nurse who transitions to a new job position, despite the reality that many will make several career moves during their professional careers. While this study did not address the issue of whether experienced nurses, who have a work history that may heighten expectations, experience more or less stress than novice nurses, it was clear that the process of transitioning was a different kind of challenge for them. Use of the strategies which emerged might benefit other experienced nurses who are transitioning into a new career role, and prevent expensive frustrations as well as lost orientations costs.