Can you feel it? The change in weather and routines? At Nursing the Future, Fall means potential! With our academic background, this season is always one of anticipation for new undertakings and a return to important work. Whether you are feeling the same or have left your academic schedule in the past (new graduates will inevitably deny ever wanting to return), we want you to join in our excitement for the possibility found in a new season!
If fall means an entry or return to a challenging environment, please connect with us. Having worked, managed, researched and led in a variety of environments over her extensive career, NTF Director Dr. Duchscher has seen it, lived it, and written the book! Please reach out to us with your needs through our social media or email!
Additionally, we've decided to reinstate our email campaigns to keep our subscribers informed about what's new at NTF. While subscribing is NOT mandatory to access NTF content, we encourage you to subscribe HERE to receive important updates on events and new content so you don’t miss out!
(https://nursingthefuture.ca/book-club/)
This month, we are featuring a feasibility report regarding Registered Psychiatric Nurse regulation in Eastern Canada. Read on to find out more, and see the full report!
Registered Psychiatric Nurses (RPN) are recognized as an important part of the provision of psychiatric health care in Western Canada. This said, in Eastern Canada psychiatric nursing care is not regulated. In May 2023, The "Registered Psychiatric Nurses (RPN) in New Brunswick, Nova Scotia, and Prince Edward Island: A Feasibility Study" was released with the intent to address both growing demands and increasing gaps in psychiatric, mental health, and addictions services in the maritime provinces of Canada. The study explored the implications of introducing RPNs in New Brunswick, Nova Scotia, and PEI to improve service delivery, support internationally educated psychiatric nurses (IEPNs), and to enhance labor mobility. The report highlighted the work of RPNs, who are regulated only in Western Canada and the Territories and practice their mental health specialties alongside Registered Nurses (RNs) and Licensed Practical Nurses (LPNs). The study, funded in part by the Government of Canada’s Foreign Credential Recognition Program, explored the feasibility of regulating and licensing RPNs in the Maritimes to improve mental health services and support internationally educated psychiatric nurses (IEPNs). It was overseen by a Steering
Committee and Regional Advisory Committee (RACs) with representatives from each Maritime province. The study involved consultations with government representatives, nurse regulators, employers, educators, and unions and examined the feasibility of support from the perspectives of education, the labour market, legal and regulatory aspects, as well as the awareness and acceptance of RPN’s among the public and other health care providers. This study recommended a viable pathway for the regulation of RPNs in the Maritimes including a legislative framework, the development of educational programs, and the promotion of RPN roles to stakeholders. Integrating RPNs into the Maritime provinces could address current healthcare gaps, improve mental health service delivery, and create more equitable opportunities for psychiatric nurses across Canada. Read the full report here! https://nursingthefuture.ca/book-club/
(https://nursingthefuture.ca/the-interview/)
Watch Judy Duchscher join the Emergency Care Research Institute (ECRI), an international non-profit organisation for safety, quality and care improvement engage in a discussion of the Top 10 Patient Safety Concerns of 2024.
The healthcare industry is currently at a crossroads. Organisations are adapting clinician workflows to new technologies, steering through changes in care delivery settings, mitigating complex risks like staff burnout and workplace violence, and navigating an uncertain economic and global political climate. Despite these challenges, ensuring patient and workforce safety across the healthcare continuum must remain a top priority for all healthcare organisations. ECRI's Top 10 Patient Safety Concerns for 2024 identifies the transition of healthcare professionals from student to practitioner as their #1 safety concern - listen to this panel of experts as they speak to this critical human resource challenge.
(https://nursingthefuture.ca/our-voices/)
This month, we are honoured to feature the story and wisdom of Lucy Barney, a First Nation woman from the Titqet and N'Quatqua Nations as she shares about her journey as a Perinatal Nurse leader. Lucy has been recognized for her nursing excellence by the Nurses and Nurse Practitioners of BC with a Lifetime Achievement Award. Lucy is known for her exemplification of visionary advocacy and work on initiatives such as the First Nation Doula Initiative. We deeply thank Lucy for her work and story.
(https://nursingthefuture.ca/awards/)
At NTF, we are passionate about recognizing and celebrating excellence. When we discover a Rising Star among new graduate nurses or their supporters, we are eager to share their successes with our community!
If you know someone who deserves to be celebrated for their achievements, please let us know by emailing us at newgraduates@nursingthefuture.ca OR go directly to https://nursingthefuture.ca/awards/ and submit your nomination! Your nominations help us shine a spotlight on those who are making a difference in the nursing profession.
Accommodating
As a result of discrepancies in the way new nurses were taught and the way the nurses around them are practicing they may feel the need to accommodate practices they see in more experienced staff without necessarily critiquing those practices for their soundness. Sometimes this happens without them even realising it (I mean REALLY—they are BUSY TRANSITIONING!), but then again, sometimes they may find themselves accommodating substandard practice because to NOT do so might be perceived as an indirect ‘challenge’ or criticism of their colleagues. Although new nurses understandably feel an immediate need to adjust their practice to what may be accepted unit practice, many later identify these discrepancies as primary factors contributing to their lack of professional fulfilment in their nursing role:
“I was so focused on knowing the routine, knowing what I’m doing, getting things done, knowing the way different nurses like things done, knowing where I fit in, what I’m supposed to be doing, when I’m supposed to be doing it. I had total tunnel vision. I was just focused on getting the job done and getting out of there on time. Then I would go home and I would feel guilty for not being more.”
“I’ve never had anyone’s blood sugar who was critically low before so I asked one of the more experienced nurses, ‘Okay, what’s the next step—like who do I call and what do I get ready and what will they probably order? I would say I was slow—slower than them. Blood—well I’ve given it a few times but I had to give a chemo drug for the first time and so I was thinking back to my orientation in the classroom: ‘Okay, what do I need to do? What do I need to check?’ So yeah it just took me 5-10 minutes to review everything, get things ready and go over in my head what I’m going to do and then going in and doing it.”
In part, this accommodation by experienced nurses may be warranted as their years of experience performing particular skills or making certain decisions and judgments repeatedly allowed them to acquire ‘tacit’ knowledge; a deep sense of ‘know how’ that comes through repeated success in dealing with varied clinical situations. Such expert knowers not only ‘see’ what others do not (relying on a deep knowledge that comes from a subconscious synergy of the senses), but ‘know’ intuitively WHAT to do, WHEN and HOW to do it, and WHY they are doing it. Invariably, the new nurse watches the application of this knowledge with awe wondering “How did he know that?” or “Will I ever be able to practice like that?”
“For me, this is what made my first few months BLOW SO SOOOO much...if you have really good role models in your workplace, you still sort of feel like a bag of dirt. But you really feel like a big bag of dirt when these nurses act like they came out of nursing school this way! It’s just nice to know that these role models once felt like I do now....”
I would be remiss if I did not speak to the frustration and disappointment some new nurses describe when they see what they believe to be archaic ways of thinking about or practicing nursing by their experienced colleagues. This includes the rigid allocation of ‘tasks’ that may be arguably outside of the job description of a professional nurse (i.e.emptying dirty linen bags or cleaning patient rooms after discharge) to their support staff, even if those nurses could do those tasks themselves. Notwithstanding the need to perform whatever tasks are needed to ensure the health and care of patients/clients (i.e. bathing and toileting patients when the NA has called in sick, sterilizing a vaginal speculum at 0200 hours on a weekend when central supply is not in the hospital because you are admitting a rape victim, or cleaning an observation room after you have urgently transferred one more stable patient to accommodate a transfer from critical care), it IS important that we ensure all those working in the healthcare environment are doing so in their full skill, knowledge and practice capacity. Nursing graduates may struggle with the expectation of assigning or delegating tasks and responsibilities to other licensed and non-licensed personnel, many of whom may be older and have more clinical experience or work seniority than them.
“What overwhelms me the most? Definitely being incompetent. Feeling like I’m not prepared to handle the patient load and delegating when I don’t even know what to delegate cause I don’t know what should be done. Where I work we have really delineated roles but sometimes I find it hard to give other people direction.
Sometimes it’s hard for me....Especially if they’ve been there longer than I have, it’s kind of tricky because we were expected to do all of the care for our patients as students so when we take on the RN role we do everything for the patients that we have been assigned.”
While it may be initially difficult to consider having to ‘tell’ someone what needs to be done, it is often more a matter of APPROACH than substance. Here are some tips for new graduates who are hesitant to delegate:
Research and Education:
The breadth of nursing knowledge extends to the pursuit of evidence through programs, initiatives, and research. Join us as we highlight and discuss what emerging findings mean for the contemporary field of professional nurse transition, and the profession as a whole.
The National Council of State Boards of Nursing (NCSBN) is an independent not-for-profit organisation that supports nursing regulatory bodies in exercising their mandate to protect the public through safe and competent nursing care. The organisation is composed of boards of nursing, whose missions are public protection. NCSBN’s mission is to empower and support nursing regulators in their mandate to protect the public. NCSBN pursues its mission to protect the public by continuously undertaking initiatives to generate evidence-based strategies and innovations. In 2002, Dr. Nancy Spector joined NCSBN as the Director of Nursing Education. In this capacity, she has spearheaded many nursing education and regulation innovations targeted at supporting new graduate nurses' transition into practice, including the Transition To Practice Model we are featuring in this column (see https://www.ncsbn.org/public-files/Evidence_Grid_2009.pdf; https://www2.ajj.com/sites/default/files/services/publishing/deansnotes/nov09.pdf).
Dr. Spector holds a Bachelor of Science degree in Nursing, a Master of Science in Nursing and a Doctoral degree in Nursing. These degrees were earned at Wisconsin University, Madison, University of California, San Francisco and Rush University respectively. Dr Spector has rich experience in pulmonary nursing, has taught undergraduate and graduate students at DePaul and Loyola Universities and was influential in forming the Respiratory Nursing Association in 1990. In 2013, She was inducted into the American Academy of Nursing for her outstanding contributions to nursing.
Theoretical Origins
Patient safety is paramount in the healthcare system so tenacious efforts are needed to ensure that healthcare professionals such as nurses are prepared during their education and supported in practice so that they can provide excellent care to all citizens in dynamic and varying circumstances. Early transition-to-practice studies conducted by renowned theorists such as Marlene Kramer, Patricia Benner and Judy Duchscher indicate that new graduate nurses need support, particularly in the first year of transitioning into professional roles. Many employers remain skeptical about the ability of the new graduate nurses to provide safe and effective care. Therefore, the onus lies with regulatory bodies to ensure new nurses receive comprehensive support that will guarantee safe patient care in clinical areas.
Transition-to-practice programs are recognized worldwide as effective approaches to integrating new nurses into clinical practice. They help to avert dire consequences such as high turnover rates and medication errors that are common among new graduate nurses. Nonetheless, variations in settings and transition-to-practice experiences demand that programmes be regulated and standardised for uniformity and consistency. Spector, in her capacity as Director of Nursing Education at NCSBN led the initiative to propose a Transition to Practice Regulatory Model (2010) that could support newly licensed nurses’ transition into practice across all settings and educational levels. The model was developed in close collaboration with the Boards of Nursing and nursing organisations after an extensive search of the literature. It was intended to be a robust yet flexible model, allowing for adaptation to a multitude of practice settings. Successful completion of the National Council Licensure Examination (NCLEX) and securing employment are the prerequisites for any transition program. Workplace orientation sessions are required for familiarisation with the workplace culture but are not considered part of transition programs.
Tenets of the Theory
The NCSBN Transition to Practice model is founded on the tenets of preceptorship, experiential learning modules and institutional support.
Preceptorship: Preceptorship is integral for the success of any transition to practice program. There is a strong correlation between the ability of the new nurse to surmount transition challenges and how well-equipped the preceptor is for their supportive role. Preceptors receive standardised training and education and are expected to work closely with new nurses for at least six (6) months, building the strong preceptor-nurse relationships that are essential to optimize learning outcomes.
Experiential Learning Modules: Five key modules, grounded in experiential learning principles, were developed to establish both the knowledge and experience required by new practitioners to provide safe and quality patient care. The modules offer opportunities to clinically reason out decisions, apply safety concepts, reflect on actions taken and receive feedback. Specific areas explored are patient-centred care, communication and teamwork, evidence-based practice, quality improvement and informatics. The five areas were selected based on evidence from the Institute of Medicine competencies and the Quality and Safety Nursing Education Initiative.
Institutional Support: The model suggests that institutional support for the new nurse must not be truncated at six months when preceptorship ends. Instead, formalized support must continue for the next six months to build the confidence and competence of the new nurse. While institutions have concerns about the cost implications of transition to practice programs, evidence indicates that the long-term benefits outweigh the cost implications of these programs.
Application of the Theory
Patient care has become increasingly complex which raises concerns about the preparedness of new nurses for their professional roles. Although transition to practice programs have the potential to bridge the gaps between nursing education and practice, variations in their setup can be detrimental to ensuring the public’s health safety. A regulatory model, such as the one presented by NCSBN furnishes organisations and facilities with both a framework and the necessary guidelines for establishing effective transition programs that meet professional standards. In addition, simple awareness that such a regulatory model exists can prompt new graduate nurses to ask potential employers questions about available institution-based supports and opportunities for professional growth intended to ameliorate the disillusionment and stress experienced during the first year of professional practice.
References
Nancy Spector. [LinkedIn profile]. LinkedIn. Retrieved June 7, 2024, from https://www.linkedin.com/in/nspector/[1]
NCBSN. (n.d.). An introduction to the National Council of State Boards of Nursing. https://www.ncsbn.org/video/about-ncsbn-an-introduction-to-the-national-council-of-state-boards-of-nursing
Spector, N. (2015). The National Council of State Boards of Nursing transition to practice study: Implications for educators. Journal of Nursing Education, 54(3), 119-120.
Spector, N. & Echternacht, M. (2010). 2009 update on the National Council of State Boards of Nursing’s regulatory model for transitioning new nurses to practice. JONA’s Healthcare Law, Ethics, and Regulation, 12(1), 12-14
Spector, N., & Echternacht, M. (2010). A regulatory model for transitioning newly licensed nurses to practice. Journal of Nursing Regulation, 1(2), 18-25
Spector, N., & Li, S. (2007). A regulatory model on transitioning nurses from education to practice. JONA’s Healthcare Law, Ethics, and Regulation. 9(1), 19–22. https://doi.org/10.1097/01.nhl.0000262489.38653.a8
Spector, N., Blegen, M., Silvestre, J., Barnsteiner, J., Lynn, M.R., Ulrich, B., Fogg, L., & Alexander, M. (2015). Transition to practice in hospital settings. Journal of Nursing Regulation, 5(4), 24-38.
Spector, N., Blegen, M., Silvestre, J., Barnsteiner, J., Lynn, M.R., & Ulrich, B. Transition to practice in nonhospital settings. Journal of Nursing Regulation, 6(1), 4-13.
Meleis’ Middle-Range Transitions Theory
The expression ‘the apple does not fall far from the tree’ epitomizes the background story of Dr. Afaf Ibrahim Meleis, Professor of Nursing and Sociology and Dean Emerita at the University of Pennsylvania. Meleis grew up having an accomplished personality in nursing as a mother and role model. Her mother’s zeal for making a difference in nursing influenced her to chart a nursing career path. After earning her first degree in nursing at the University of Alexandria in Egypt, Meleis was granted a Rockefeller Scholarship which supported her travel to the United States to pursue a Master of Science in Nursing degree at the University of California, Los Angeles (UCLA). Two years after earning her MN degree, Meleis earned a second Master’s Degree in Sociology at the same university. Continuing her reach, she completed her Doctorate in Philosophy focusing on medical and social psychology and for 34 years maintained a faculty member status at that same University. Dr. Meleis initially accepted an academic position as an Assistant Professor at UCLA, and later moved to San Francisco, continuing on to become Full Professor at the University of California, San Francisco (UCSF) School of Nursing. She was instrumental in the introduction of doctoral programs in nursing at UCSF, emulating her mother who played a key role in the establishment of nursing undergraduate and postgraduate programs in Egypt. Her involvement in the Kuwait educational system led to the establishment of an independent nursing program at the University of Kuwait.
In 2002, Meleis moved to the University of Pennsylvania, performing dual roles as Dean of the Nursing School and Director of the WHO Collaborating Center for Nursing and Midwifery Leadership. During her tenure, the school made significant strides in education and infrastructural development. Dr. Meleis is passionate about empowering women and advancing the nursing profession and has been recognized internationally for her extensive contributions to women and migrant health. The impact of her research on transitions is far-reaching and utilized worldwide to enhance ongoing transitions in healthcare. Dr. Meleis has received numerous prestigious awards such as the Living Legend from the American Academy of Nursing, the Nell J. Watts Lifetime Achievement in Nursing Award, an Honorary Doctorate of Medicine at the Linköping University in Sweden and Doctor Honoris Causa at the University of Alicante in Spain. She was inducted into the Nursing Hall of Fame at UCLA and UCSF and recently received a medal for National Humanism in Medicine. Dr. Meleis has mentored many individuals and continues to pass on her wisdom and knowledge in the advancement of the nursing profession.
Theoretical Origins
Through her extensive program of research, Dr. Meleis became increasingly aware that the nursing practice was imbued with numerous transitions; nurses always interact with individuals who are going through transition in one form or another. She believed the nursing profession would benefit from recognizing transitions as one of the central concepts in nursing. Nurses who are often responsible for providing support for transitions require some form of guideline to support healthier outcomes. It was within this premise that Meleis’s transition theory evolved. Role theory, the perceived view on lived experiences and feminist post-colonialism were the foundational paradigms that helped shape her line of thought and query. The goal of the transition theory was to provide a framework that outlined the experiences of persons going through a change and inform support strategies for managing these new experiences. Numerous studies were conducted through the years and the collective findings were used to formulate the theory’s framework.
Tenets of the Theory
Transition is internal and defined as “a passage from one life phase, condition, or status to another” (Chick & Meleis, 1986). As individuals interact with their environment, events and changes occur, shifting the individual from one state to the other. The events or changes may be occurring within the individual or in their environment, and result in alterations that are responded to by the individual. It can be a process, or an outcome of the person’s interaction with the environment. Transitions are preceded by triggers (events) that are either developmental (life phases manifested by age or roles), illness/health-related (changes in health or illness resulting in a diagnosis or an intervention process), situational (changes resulting from a shift in environment or circumstances) or organisational (changes in organisational environment).
According to Meleis, transitions are often not discreet and an individual can experience multiple transitions simultaneously. Transitions have characteristics called properties that highlight crucial areas that can affect the transition process, including: time span (periods that move from an awareness of the transition to full adjustment), change and difference (recognizing the disparities between reality and expectations), engagement (involvement in the transition process), awareness(the level of knowledge, perception and recognition of transition) and critical points (milestones in the transition process). Correlations also exist between the individual’s transition outcome and their transition conditions. Transition conditions are thefactors that facilitate or inhibit the transition process encompassing personal, community and societal factors. Personal conditionsare the factors directly related to the individual such as the meanings they attach to their transition process, their cultural beliefs and attitudes, their socio-economic status and the preparations and knowledge about the transition process. The prevailing conditions within the community where the transitioner dwells affect the transition process. The availability, access and type of human and infrastructural resources determine outcome trajectories. The broader societal norms have a bearing on transition outcomes as well; when support is inadequate, the transitioner can experience marginalization. The types, patterns, properties and conditions of transition influence the transitioner’s responses to the ongoing changes. The nurse’s consideration, understanding and awareness of these crucial aspects of transitions enhance the identification of best support strategies for attaining healthy and positive transition outcomes.
Given that transitions can either be a process or an outcome, the concept has two patterns of responses: process indicators and outcome indicators depicting the transitioner's responses while undergoing the transition. Process indicators include feeling connected (maintaining ties with people), interacting (level of engagement in the transition process), location and situation (recognizing one’s position in the complex series of events) and confidence and coping (ability to deal with circumstances). Outcome indicators are two-fold: mastery (demonstration of skills denoting control over events) and developing fluid integrative identities (reforming identity and the ability to switch between identities based on expectations). The nurse’s assessment of the patterns of responses in transitioners ensures that potentially negative outcomes are interrupted with timely support. The transition experience is similar yet unique to each individual, hence the framework of Meleis’ transition theory is a useful tool for nurses to develop nursing interventions and therapeutics for patients and their families.
Application of Theory to the New Graduate Nurse
The framework of Dr. Meleis’s transition theory can be leveraged by nurse leaders and managers to enhance the transitioning experience of new graduate nurses. New nurses who are transitioning into their professional roles can be assigned mentors and coaches who will interact effectively with them to identify the nature of the transition they are undergoing. An effective interaction can shed light on the unique experiences of the newly graduated nurse and help identify personal, community and societal factors that might interfere with the new nurse’s successful transition. In building the capacity of the new graduate, the transition properties can be applied to enhance their integration. Nurse leaders' efforts should be directed towards increasing the awareness of new graduates to the changes occurring around them and providing support that is multifaceted and holistic. Guidance in adapting to new roles, encouragement to engage actively in the transition process, and taking note of key milestones while providing feedback as needed should form an integral part of the support strategies. Nurse leaders must finally recognize that new nurses will develop competencies over time with the right support.
References
Bodziak, S. (2024, May 28). Empowered by her education, scientific rigor, and passion for mentorship, Dr. Afaf Ibrahim Meleis transformed nursing - The Arnold P. Gold Foundation. The Arnold P. Gold Foundation. https://www.gold-foundation.org/newsroom/news/dr-afaf-ibrahim-meleis-transformed-nursing/
Chick, N., & Meleis, A. I. (1986). Transitions: A nursing concern. PL Chinn (Ed.), Nursing research methodology: Issues and implementation, 237-257.
Meleis, A. I. (2015). Transitions theory. Nursing theories and nursing practice, 4, 361-380
Meleis, A. I., Sawyer, L. M., Im, E., Messias, D. K. H., & Schumacher, K. (2000b). Experiencing Transitions: An Emerging Middle-Range Theory. Advances in Nursing Science, 23(1), 12–28. https://doi.org/10.1097/00012272-200009000-00006
University of Pennsylvania School of Nursing. (n.d.). Afaf I. Meleis. Retrieved July 11, 2024, from https://www.nursing.upenn.edu/live/profiles/69-afaf-meleis
Wikipedia contributors. (2024, June 26). Afaf Meleis. Wikipedia. https://en.wikipedia.org/wiki/Afaf_Meleisulty confidence and student implementation of anti-racist practices. Additionally, increasing Indigenous representation and advancing Indigenist pedagogical approaches should be further explored. Pedagogical innovations such as this course can build relationships and disrupt systemic racism in nursing schools.
Our popular seminar series NTFLive is back with another amazing seminar planned! Join us in the live session discussing all things urgent in 'When Things Go South: Responding in a Crisis" on September 19 at 2pm EST with critical care experts and frontline nurses. Don’t miss this important and engaging session designed to hone your skills responding to critical events. Watch our Social Media and become an NTF subscriber for updates and your FREE tickets! Be sure to share these events with your new graduate peers, coworkers, and senior students!
After more than twenty years of national leadership in supporting nursing students and newly graduated nurses through professional role transition, Nursing the Future (NTF) is concluding its current operational chapter.
Since 2004, NTF has served as a vital bridge for new nurses, educators, and leaders navigating the vulnerable early months of practice. Through evidence-based programming, national partnerships, and a commitment to building a safe “cul-de-sac” for early-career nurses, NTF has supported thousands across Canada in cultivating connection, confidence, and professional identity.
We extend deep gratitude to our partners, including the Canadian Nurses Foundation, the Canadian Nurses Association, the Canadian Nursing Students Association, provincial ministries, healthcare institutions, and countless contributors whose belief in transition-to-practice support made this work possible.
While formal operations conclude, the scholarship, curriculum, intellectual property, and program infrastructure developed over two decades remain intact and available for strategic partnership and collaboration. For further dialogue on potential collaborations, please contact Dr. Duchscher directly: newgraduates@nursingthefuture.ca
We welcome conversations with ministries, health regions, academic institutions, and professional associations interested in advancing initiatives such as:
The mission of healthy and supported professional role transition remains urgent. The work continues, sustained through scholarship, partnership, and shared commitment to the future of Canadian nursing.
With enduring gratitude,
Dr. Judy Duchscher - Founder & CEO, Nursing the Future
Kathryn Corneau - Program Director, Nursing the Future
For our FULL letter of Gratitude CLICK HERE
