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Engage new nurses with CARING

Vess, Kellee R., PhD, RN; Russell, Jeffrey A., PhD(c), MA

doi: 10.1097/01.NUMA.0000538911.30288.72
Feature: CE Connection

Help novice nurses navigate the uncertainties of first-time employment with the CARING model, which promotes workplace wellness by fostering coping strategies for daily practice.

In Knoxville, Tenn., Kellee R. Vess is an assistant professor and the RN-to-BSN program director at Tennessee Wesleyan University and Jeffrey A. Russell is an assistant professor at Pellissippi State Community College.

The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

For more than 143 additional continuing education articles related to management topics, go to NursingCenter.com/CE.

Earn CE credit online: Go to http://nursing.ceconnection.com and receive a certificate within minutes.

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Connecting current academic culture to the workplace begins by looking at our broader American culture, especially the American ideology of happiness. This culture is often influenced by consumerism and the desire for positivity and instant gratification.1 The concern with this ideology is that it leads to a lack of imagination about potential setbacks, which results in a lack of effective coping mechanisms when an individual experiences loss or failure. This issue becomes even more important when dealing with the challenges of full-time employment and adapting to an ever-changing healthcare environment.

In the nursing world, an increased sense of entitlement or wanting recognition and praise despite perceived effort can diminish the quality of bedside nursing practice. In an effort to lessen this cultural shift, we offer nurse educators, managers, and others involved in mentoring new graduate nurses insights from academia about beneficial strategies for helping new nurses navigate the uncertainties of first-time employment.

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Academic entitlement

Current research has implied that there's been a shift in entitlement behaviors within the academic setting, and these entitlements can become a learned behavior that can be carried into first-time employment. In the classroom setting, academia has termed these behaviors and attitudes academic entitlement (AE), which is rooted in an overall generalized sense of entitlement.2 AE is “a stable and pervasive sense that one deserves more and is entitled to more than others, and it is experienced across situations.”3 AE also refers to a student's tendency to expect to receive high reward, high grades, or preferential treatment without investing significant time, effort, or responsibility in his or her own learning.4,5,6 Overall, AE equates to wanting more recognition with less effort and, if not received, deflection and other-blaming are used as coping mechanisms to protect the entitled sense of self-worth.

As this field of research expands, researchers are now looking to determine what causes AE. One of the earliest researchers of AE suggests that it has three main causes.7 The first is student protest, which has proved more efficient than academic effort in gaining formal reward. Second, there's been a cultural shift of the burden of responsibility, which yields the conclusion that if a student fails, the fault can't lie with the student; rather, it must lie with the teachers, curriculum, institution, or, more vaguely, the “system.” Third, the culture of entitlement has a strong tendency either to occlude “achievement” entirely, or “delegitimize” it by inducing skepticism about its point or purpose, especially in the field of education.

Although this perspective has been more focused on students, educators may play a role in promoting AE when there's a lack of understanding of expectations between the educator and student.8 Educators may also be promoting entitlement through grade inflation, failure to promote and model self-regulation and self-efficacy, and by ignoring incivility from both sides of the classroom (teacher and student incivility).5,9 Sometimes these issues are due to problems such as senior faculty failing to support junior faculty or low faculty morale that affects classroom practices.9,10

The current literature on AE implies that the new generation of nurses may have specific orientation needs that aren't being addressed by previous orientation strategies. For example, if students who scored higher on AE scored slightly lower on the measurement scale for self-esteem, then efforts should be made to address their issues with self-esteem and teach them how to develop their identities as nurses. Research has shown a positive correlation between AE and workplace entitlement, which has the potential to cause decreased job satisfaction, lower satisfaction with pay, and less commitment to the organization.11 There's also a negative association between work orientation and AE.5 In fact, AE has an inverse relationship to work orientation and social commitment.5 Teaching relational and positive coping skills can redirect the new nurse's attention to developing healthy work relationships.

Finally, today's work environments are unique in that there are four different generations actively engaged in our current workforce: the silent generation, baby boomers, generation X, and generation Y (or millennials). Each generation can be assigned certain characteristics related to their beliefs about work. For example, the silent generation (1928 to 1945) is described as valuing “honesty, organizational loyalty, conformity, and a work ethic that incorporates hard work and moral values.”12 On the other hand, millennials (1982 to 2009) have “loyalty to individual managers (not corporations), a commitment to idealistic corporate vision and values, and a willingness to provide an employer with hard work, albeit for immediate reward and recognition.”12

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From classroom to practice

Being an educator, mentor, or preceptor to new graduate nurses is both challenging and rewarding; with the influx of multigenerational nurses, a whole new set of challenges has emerged. For example, how do older generations perceive the actions and behaviors of new graduates, and have younger nurses truly acquired the social/relational skills needed for this caring profession? Without these essential social and relational skills, some clinical behaviors may be interpreted as exhibiting a high sense of entitlement. Some examples of entitled clinical behaviors include a lack of participating in basic patient care tasks, such as bathing and oral care; not offering to help other nursing staff when available; and focusing on one's personal cell phone instead of on patient needs. Are these issues more related to the dynamic interplay of multiple generations cocreating our current nursing culture or can they provide insights into how new graduates react to their environment during this transitional phase?

To take a deeper look at the changing faces of practice, the first place to start is understanding why new graduates are selecting nursing as their career. The second step is to explore why about 17% of new graduates decide to leave the profession within 1 year of starting their first nursing job.13 In one qualitative study, the researchers found that “the problem with an emphasis solely on the virtues of becoming a nurse is that it can deemphasize the knowledge, skill, and experience required within nursing practice.”14 In other words, one reason for dissatisfaction in nursing for new graduates is not the virtuous reasoning for choosing to become a nurse, but rather a lack of real-life experiences, which has resulted in a lack of coping skills for everyday practice.

A transition is “a process of changing from one state or condition to another, and in the context of nursing, transition can be defined as a period where new graduates undergo a process of learning and adjustment, and a socialization into a new culture.”15 This is viewed as a rite of passage in becoming accepted in the profession. Since new graduates are the future of nursing practice, concerted efforts need to be made to support them during this transitional phase. Creating an environment for a positive transition can be difficult due to the expectations, needs, and demands of the new nurses entering the workforce.15 Despite these expectations, many newly qualified nurses want to communicate freely with their supervisors, understand their role in a team framework, and be accepted into the workplace culture.15 By creating a caring culture in the work environment, newly hired nurses can feel a sense of loyalty, commitment, and opportunity while learning new roles and responsibilities.

In this period of transition, new nurses face different struggles and experiences that can affect organizational commitment and retention, and, ultimately, lead to increased employee turnover.16 Millennial staff members can be hard to retain because they're younger, have less experience in the workforce, and are more likely to believe—rightly or wrongly—that the grass is greener elsewhere to help put their current position in context. This is why nurse managers should strive to “improve working conditions to improve both patient and nurse satisfaction, as well as quality of care.”17

To create change with incoming millennial nurses, hiring managers must understand that millennials have lived tight, structured lives, and many of them haven't learned the skills needed for workplace demands. Managers and educators must teach them skills such as independent decision-making, organization, and time management. In the context of the workplace, nursing educators can promote successful change with new nurses by clearly defining the expectations and goals of the job, and being clearly explicit with communication, direction, and feedback.18,19 Whether in the workplace or the classroom, nursing educators need to model excellence for new nurses to help build knowledge and confidence.18 Also, nursing educators must promote the workplace environment as a collaborative and caring atmosphere to help foster learning opportunities and mentorship.20 By doing so, they help change the climate of entitlement to one of gratitude and care.20 This climate can bridge the gap between being the expert student and being a novice nurse, and it can provide new nurses with a holistic process or framework to develop the functional coping skills to manage the stressors of daily practice.

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Development through CARING

As we move forward in our efforts to aid new nurses in gaining the functional skills needed to manage the stressors of daily practice, we must also become increasingly aware of the major challenges facing new graduate nurses. Some of these challenges include an “increased number of patients with complex conditions, lack of access to experienced mentors, generational diversity, performance anxiety, and bullying; often these problems occur simultaneously.”21 The importance of understanding these challenges is that without recognizing them, new graduates may experience high levels of stress; without proper care and intervention, this uncontrolled stress can lead to costly turnover rates and professional burnout.22 To address this problem, we can help new graduates develop through the application of a CARING framework.

In its original form, the CARING model was developed for the academic setting. However, after positive feedback from experts in the field of adult learning, it's been expanded to address potential stressors that new graduates may encounter during the time of transition. This approach focuses on six essential behaviors or skills for navigating the mental demands of daily work: self-compassion, acting and reflecting, intentionality, navigation, and self-regulation. Although the model appears linear in nature, it's an evolving and recursive cycle. (See Table 1.)

Table 1

Table 1

This process begins with self-compassion, which is the development of an appreciation for not only the limitations of others, but also for oneself. By understanding self-compassion, an individual can begin to appreciate his or her strengths and abilities versus focusing on weaknesses, which starts the journey to workplace wellness. With an increased focus on strengths, the new graduate's positive attributes are amplified and his or her weaknesses, although not ignored, are minimized. For example, persistence is a focus on obtaining goals despite obstacles, which allows a new nurse to focus on his or her goals instead of the difficulties encountered during beginning practice.23

Next, it's through reflection on these positive actions that an upward spiral of positive adaptation and coping occurs. As more positive reflections and actions build, relationships between the new nurse, coworkers, patients, and others improve because creating a caring culture has become an intentional decision for the new nurse. In return, this helps the new nurse navigate his or her work environment and creates a sense of self-control over that new environment, which finally leads to self-regulation, or the ability to control how a person reacts to changes in his or her environment.2

To help new nurses become self-regulated in their practice, we propose applying adult learning strategies throughout orientation, such as reflective practice, art, music, blogs, podcasts, verbal journals, poems, gratitude letter writing, gratitude lists, and short stories regarding significant events. These strategies offer individualized options for facilitating and promoting well-being, and enhancing the level of gratitude.17,24 Creating a simple gratitude list can yield feelings of positivity and well-being.25 Gratitude writing or reflecting on events for which nurses are grateful is an effective method for promoting self-healing and self-care, which can enhance job satisfaction and diminish work-related stressors.17 We propose that the ongoing implementation of these strategies can produce positive outcomes by fostering growth in coping skills, building cognitive and social resources, and developing positive outcomes in daily social and professional relationships.26

Newly hired nurses can use these strategies to structure and find meaning in their new experiences. By looking at these experiences with a positive approach, they can resolve issues by managing their emotions.27 In addition to managing their emotions, these new nurses will be more likely to be proactive in maintaining a positive work environment.26 Overall, those who practice and rehearse positive intervention strategies exhibit more positive well-being and are more likely to become self-regulated. Based on this information, one specific strategy that we believe should be used for implementing the CARING model is expressive gratitude journaling. This type of journaling focuses on writing about personal ideas related to thankfulness and appreciation.28

Gratitude journaling can be as simple as a daily listing of three to five things for which an individual is grateful or as complex as writing letters of gratitude with specific details to coworkers, managers, patients, educators, and so on.20 This activity can be implemented easily and with little preparation for any orientation or nurse residency program. In fact, developing a meditation practice emphasizing gratitude has been shown to improve well-being, self-compassion, and confidence in providing compassionate care for healthcare professionals.29 Finally, developing an intentional practice of gratitude, compassion, acceptance, forgiveness, and higher meaning improves resilience among new nurses and decreases levels of stress and anxiety.30

As new nurses write, reflect, and discuss how gratitude shapes their worldview, they can make greater connections between their past experiences and their ideal future selves. By learning how to connect their worldview to their own experiences, nurses learn how to “find out more about themselves, to appreciate the support that is available to them, and to recognize that the situation is making them more patient, empathetic, and less judgmental.”25 Overall, new nurses can gain a sense of understanding and meaning, provide a sense of control over emotion and experience, and integrate ideas of self-understanding by using expressive gratitude journaling.31

By moving through the CARING model process using expressive gratitude journaling, nurses have opportunities to reevaluate difficult situations, develop a sense of courage, and create spiritual and personal growth.25 Also, expressive gratitude journaling can “hone reflective skills, help new nurses process experiential learning activities, and encourage personal growth and professional development.”32 Overall, expressive gratitude writing helps new nurses gain a sense of understanding and meaning of their experience, and provides a sense of control over their emotions.32

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Positivity matters

The CARING model promotes workplace wellness through fostering proactive coping strategies. It reframes the new nurse's focus from the negative and restores attention and effort on the positives he or she can appreciate about daily nursing practice. This intentional refocusing and reframing of experiences or stressors allows the new nurse to choose how he or she responds to uncontrollable situations. It's hoped that if positivity begets positivity, new nurses can get back to the altruistic reasons for why they joined the profession, and, ultimately, will choose to stay in bedside practice.

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INSTRUCTIONS Engage new nurses with CARING

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This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 1.0 contact hour, and the District of Columbia, Georgia, and Florida CE Broker #50-1223.

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