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New Nurses Face Reality Shock in Hospital Settings – So What Else is New?

July 27, 2009
From Jason Pratt, via Flickr

From Jason Pratt, via Flickr

A new report in Nursing Outlook (here’s the abstract) analyzes the experiences of new nurses. The news is not good. Actually, it’s really pretty awful when you think that much of what theses nurses complain about was documented in a book published in 1974 by nurse and researcher Marlene Kramer, Reality Shock: Why Nurses Leave Nursing.

The current report analyzes the nurses’ answers to an open-ended question that was part of a larger study of newly licensed registered nurses who’ve been employed less than 18 months. Researchers identified five themes among the 612 comments:

Colliding expectations – The nurses expected the workplace to be more in keeping with what they were taught in nursing school; “high patient-to-nurse ratios were a particularly dominant source of stress.”
The need for speed – The nurses felt there should have been more time for them to transition to carrying full responsibilities for patient care.
You want too much – There were many complaints about the heavy workload, with little time to do it and little time to spend with patients.
How dare you? – The nurses felt they were mistreated by nurse and physician colleagues and management.
Change is on the horizon – Despite the many complaints about the workplace and the workload, the nurses described a hopefulness that things would improve.

The authors note that these are long-standing issues and that it makes one wonder “how seriously leaders have considered the concern of nurses at the bedside.”

While most of these nurses (75%) worked in non-Magnet facilities, that leaves 25% who were employed at Magnet facilities, showing that achieving Magnet certification does not guarantee a workplace free of angst (and that’s an unreal expectation, anyway).

One thing that’s changed. I was a new graduate when Kramer’s book came out and could identify with much of it. My initial job was in a city-run hospital where resources were limited (one of the first things you learned was to find out where your colleagues hid their secret stashes of linens) and the workload was tough (in working as an LPN in my senior year, I was the only nurse with two aides on a 24-bed medical/surgical ward – yes, ward).

So yes, the workload was tough and yes, we dealt with unappreciative physicians and department heads, and yes, I wished I had more time to “learn the ropes.” As new nurses, we had one week of orientation and then we were assigned to the units where we would work.

The difference I see between my early experience as a new nurse and what seems to be the experience of many new nurses today is the support I and other new nurses received from more senior colleagues. Perhaps that is what made the workplace problems bearable.

The nurses on the unit where I was to work (Bellevue Hospital’s emergency ward) took pride in the reputation of the unit and wanted newcomers to continue what they had built. They were invested in our success. I spent the first few days working with an experienced nurse who watched and coached me in performing interventions I didn’t feel comfortable with or had never performed. She cheered my success and always ended our experience by saying, “See? You can do it.” The head nurse would frequently check in with me, asking “How’s it going?” and then really listening to my responses. The support of colleagues outweighed the problems—we were all in it together. My classmates at neighboring facilities echoed the same sense of becoming part of a team all working together; it was how we were socialized into the profession.

It seems that this is a far cry from what most new nurses experience—there are too many reports of bullying behavior to dismiss it. So how is it that this sense of nurturing the next generation seems to have disappeared from so many workplaces? What are we going to do about it? What is it like at your workplace?

Shawn Kennedy, editorial director
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19 comments

  1. Nurses represent the largest group in the medical profession. Just think about the things we could change (for the better), if WE ALL stood together!? It could be amazing.

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  2. I left my first nursing job at the 8 month mark due to bullying and lack of support. The stress was so severe I would dry heave in my care before my shift after voicing my concerns about job stress many of my co-workers stated this was the norm either ride it out or take anti-depressants (many of the nurses I worked with did). The management required us to burn the candle in providing quality care and improve patient satisfaction…and DO NOT pass any work off to the night shift! Needless to say the culture of nurses eating their young is the only tradition that has survived in nursing.

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  3. I have been a nurse for 33 years this month, started with a BSN and get my MSN…I have never understood nor practiced the “eat your young” philosophy but yes, it is there. It is such a waste of time and energy when we could be providing even better care to the patients/residents we are supposed to be caring for. Work together….If I were responsible for picking preceptors I would interview them carefully….when I worked in management I made sure the experienced staff remembered what it was like. I don’t think its a difference between education levels…I had great clinical and no unrealistic expectations leaving my BSN program in 1981 (when the debate was still raging)…by senior year no one should be unaware of the work load and clinical experiences should be adjusted to help with this expectation. We worked 32 hours a week side by side with a nurse our last semester….with gradually increasing responsibility. The transition to work was no shock. If you don’t want to work hard, miss some meals, work weekends and holidays…..then do not pick nursing as your career. Its damn hard work but incredibly rewarding and often quite fun.

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  4. I hear a lot of comments about nursing students being lazy. I am a new grad and have felt looked upon as lazy however, these days as others have said with liability you are watched like a hawk and often times can’t do much because we are not allowed. We couldn’t even get blood sugars on our patients because you have to be able to log into the device. We do over 800 hours of clinicals, you can only watch nurses walk around, chart, talk, take blood sugars etc for so long that you become bored out of your mind. At a certain point there is only so much you can learn by shadowing and watching before you feel like you want to put your head through a wall. At that point I would often feel I could learn more by studying than watching blood sugar number 599, or taking vitals for that thousandth time. Many nurses take advantage of students and just make them do their work they don’t want to do, and it’s not about learning. I was a CNA for 4 years and felt like the nurses would use me as their personal CNA. Every facility you do rotations in is different so it is not beneficial to try to master every hospital computer systems in a matter of days. The training compared to the demand is not comparable.

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  5. It is the responsibility of experienced nurses to prepare the nurses of the future. We should all remember that we were new grads at one point and welcome the opportunity to build excellence in the profession. If as an experienced nurse teaching and training the next generation of caregivers is a hassle, then perhaps it is you who are in the wrong profession.

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  6. I have been blessed with a wonderful nurse leader that believes that mistakes made are an opportunity for education, not disciplinary action. He has been a wonderful mentor. I also have been blessed with a charge nurse that took me under her wing and mentored me during my first year in the profession, and she has become a very good friend. All the other nurses on the unit have been friendly and helpful too. I have learned to manage my time, juggle a patient load of 1:7 most days while managing to give safe and quality care, and develop confidence in my skill set. Our nurse manager works diligently to staff us properly so that we have an appropriate number of nurses and support staff so that we don’t feel overwhelmed, unfortunately those efforts aren’t realized all the time as we are having to lend staff to other departments. All in all I think I found the best of situations for me to start my career and I have gained an excellent base of knowledge and experience to build the rest of my career on. Good luck to all of you. I hope everyone can find a similar situation, from the sounds of it most haven’t yet.

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  7. As I reflect on this Nursing Blog, I must say that nursing today is very much similar, to a “Nurse Jackie” episode. Nurse Jackie is the prime example as to what it means by “Nurses Eat Their Young.” Senior nurses are so overwhelmed with Hospital Magnet Standards that remembering to be humble, soft spoken and protective of new nurses just adds as an irritant to their everyday stressful nursing tasks. I believe our new generation nurses will get a indebt understanding of what it means for “tough love” in nursing. New nurses will have to “ put up or shut up”. It ain’t no crying in nursing, leave the tears at the Chapel or at home. There too much stress , in a high pace working environment to be overthinking ant moping about nonsense. Priority and time management is the key make or break it factor as to well a new nurse will love his or her new job or simply change their profession.

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  8. yes the problem continues .The senior nurses treat the young RN as replacements for their senior nurses and oh Yes they report incidences (mistakes done by young nurses ) for disciplinary action.They do not mentor and practice preventive strategies .The young nurse is discouraged to leave .I wonder if the older/senior nurses love their profession and if they do would they drive the young ones away ?

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  9. […] 4. New Nurses Face Reality Shock in Hospital Settings – So What Else is New? We ran this one two years ago, but it’s as relevant as ever for nurses who’ve just graduated from school and are starting out in a new job—and for the nurses who work with them. […]

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  10. […] New Nurses Face Reality Shock in Hospital Settings – So What ElseActually, it’s really pretty awful when you think that much of what theses nurses complain about was documented in a book published in 1974 by nurse and researcher Marlene Kramer, Reality Shock: Why Nurses Leave Nursing. […]

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  11. As a new LPN who is continuing on in an RN program. I too, received only 5 days orientation in an 85 bed LTC facility with a 2:42 ratio. The support from most of the nursing staff has been wonderful. The support from the NAs & CNAs has been very disappointing. I have been there 6 weeks and have not had a break or dinner yet. I’ve learned that have to eat before I go into work. I do managed to grab a soda while charting. I left a job making more money with full benefits to go to school to become a nurse (a 30year dream). I will keep looking for a position that fits me and the kind of care I want provide so that I can stay in nursing. Keep looking for your fit and don’t get discouraged. Good luck to all.

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  12. It’s amazing to me that 21 years later, the issues are still the same. I remember being thrown out there as a new grad and was expected to perform as a seasoned nurse. Thank goodness for some wonderful LPNs that weren’t threatened by my RN applicant status. Instead, they were caring, supportive people that took me under their wings and made me the RN I am today. I’m so glad that I no longer work a 21 bed unit with an LPN and praying for an NA to help. I could write a book of the many horrors I faced during my 13 years of bedside nursing. The only people that would believe it would be my fellow nurses that have probably experienced similar situations. One thing about nursing is you have to love it. For someone who said everyday in nursing school that I was going quit, I’m surprised that I’m still going. It’s all for the patients. I hope I’ll still be at in 20 more. Take care.

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  13. I agree that new nurses, many of them, have what they term as “issues”. These issues are not cleaning up poop (oh horrors), changing dirty dressings, just plain ole taking care of their patients. Some are just lazy. As a retired 70 year old who kept working for the love of nursing and what I could do until I was 69, i am ashamed that the head nurses do not support their nurses more–and that includes the “directors”. Well to be fair, nurses do have more than they can handle but more nursing assistants could help too.

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  14. I left nursing for the reasons listed. In nursing school, you are watched like a hawk, because professional nursing liscenses are on the line if a nursing student makes a mistake. You graduate, pass the state board, hired, take week orientation, wham-O– you’re expected to take full patient care load plus all the other responsibilities. I hope that includes two, ten min. brakes, and 30 min lunch?? Suddenly, no one cares about you, or your professional growth as a nurse.

    Sorry, I became an RN. I should have been a ditch digger.

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  15. I have seen numerous new grad nurses with difficulty starting out in their career, as well as some who have done extremely well. When I was in nursing school 6 or 7 years ago we worked to the bone! Indeed, half of our starting class was lost to grades and stress but I feel I am better for that. And I have to say that many of the nursing student clinicals I see learning on our unit are very lazy, for lack of a better word. They sit around the nurses station, chat with other students, and read their textbooks. They only want to be involved in interesting procedures…little do they know nursing is not about that.

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  16. You academicians can say all they want about diploma schools, but when I started as a new graduate 45 years ago, I had no illusions about my career or my role. I had already spent years learning from senior nurses, doctors, interns, medical residents, and professors in a clinical setting,where I provided hours of nursing care. In my hospital,the nursing students were the back-bone of the nursing staff. We also had co-workers who were not supportive, but most wanted us to succeed so we could improve the level of care.
    Later, working in a NYC hospital ER at night,I was pulled to cover a 60 bed surgical unit with 2 aides. I refused to go knowing I would put patients at risk. (My supervisor agreed.)
    Take care of your patients, but take care of yourself as well. Keep learning, keep serving. You will never regret it.

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  17. […] long ago AJN editorial director Shawn Kennedy blogged here about a new report in Nursing Outlook on the “reality shock” that new nurses experience. The […]

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  18. It’s sad to me, still a relatively new nurse, that nurses today face the same work issues nurses faced 30 years ago. I agree also that the environment of one’s floor makes a huge difference, and that levels of support can very widely. I started on a floor where the new nurses were routinely bullied by some of the senior staff. Then I transferred to a different floor where staff were much more professional and much more supportive. If I had stayed on my old floor I probably would have left nursing.

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  19. You write, “The difference I see between my early experience as a new nurse and what seems to be the experience of many new nurses today is the support I and other new nurses received from more senior colleagues.”

    I daresay, the biggest difference between nursing “back in the day” and nursing nowadays is the acuity of the patients and the incredibly shortened lengths of stay, making everything so much more fraught with communication problems and time management.

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