Protection versus surveillance

However, this period was not without problems as the participants described a tension between the feelings of protection from facing potentially difficult clinical situations on their own – which they welcomed; compared to the discomfort associated with being watched. Here, Nasim, Tyler and Jesse all acknowledged the physical presence of a preceptor as supportive.

“I think in terms of support from colleagues, I feel as supported as I was as a student, I’m quite lucky really” Jesse.

“We have been supported … as newly qualified … a lot and you're always guided … you're always shadowing a nurse or the nurse is shadowing you” Nasim.

“It was a case … we were very protected for three months and then we came out of that supernumerary period” Tyler.

Jesse compares this to her time as a student giving some indication of the level of protection she felt, and that she was “lucky” implying that this kind of protection was not available to everyone. The opportunity to undertake joint supervised visits was seen as a distinct advantage, giving an opportunity to build on knowledge in a protected environment which in turn increased their confidence:

“I think having preceptors and being able to do joint visits was an advantage most definitely” Max.

“I think that’s helped me to grow in confidence, that experience of being supported has helped me grow and certainly it’s helped me build on my knowledge” Jesse.

The benefits of supervised practice during the initial stage of a new post is a very well documented aspect of transition and this type of support has been widely recognised as a

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process that helps to ameliorate negative experiences of transition (Kramer 1974, Boychuk Duchscher 2007). Studies by Gerrish (2000); Jackson (2005); Leigh et al.,(2005); Beecroft

et al.,(2006); Maben et al.,(2006, 2007); Berridge et al.,(2007), and Clark and Holmes (2007) all support the notion that good formal support is highly valued by newly qualified nurses during their experiences of transition since it has a significant impact on their ability to cope with the demands of the job and is thought to lead to perceived stress reduction. Similar findings are also found in studies of midwives, other health care professions and doctors who also value support from senior colleagues during transition. Here, effective support is reported to have a significant impact on the ability to cope with the demands of the job and increase confidence levels where the preceptor helps with assimilation into the new role (Amos 1999; Gerrish, 2000; Brumfitt et al.,2005; Jackson 2005; Beecroft et al.,2006; Maben et al.,2006; Berridge et al.,2007; Clark & Holmes, 2007; Lauder et al., 2008; Thomas et al, 2008; van der Putten, 2008; Morley, 2009; and Brennan et al., 2010). Similarly Godinez et al.,(1999) claim that having regular contact with a supervisor for feedback, advice and answering questions helped during the initial transition period, which in turn, leads to a reported increase in confidence in clinical skills (Bick, 2000; Berridge et al, 2007). The findings in this study therefore reflect the findings in the literature which support the notion that the physical presence of a preceptor as a supportive individual helps newly qualified nurses during their transition.

For these participants, one of the benefits of the shadowing period appeared to be related to allaying their anxieties associated with being accountable, described by Max as “a big cloud”:

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“As we were coming up towards qualification there was kind of this big cloud stuck up here with the big word accountability written on it and that was quite scary”. But when I did start work because of the induction process and because I was able to go out with more senior members of staff all the time it wasn’t that scary”.

Here, Max described an acute awareness of a perceived increase in accountability associated with qualification and that this provoked a negative emotional response. Anxiety associated with accountability amongst newly qualified nurses has been discussed by Gerrish (2000) and Whitehead (2001). They suggested that newly qualified nurses' perceptions of their transition experiences were strongly linked to the concepts of responsibility and accountability and that perceptions of increased accountability are reported as a stressful aspect of transition. This is because they perceive themselves as not being fully prepared for the change from being a supervised individual with responsibility for their own actions to an individual fully accountable for their own actions. However it is clear from the quote that Max’s worries and concerns were not realised at this point which she attributed to the period of shadowing where she enjoyed protection from the stress of accountability through the physical presence of a senior member of the children’s community team.

The period of shadowing during the initial stages of transition was therefore a facilitator in the process of transition for these participants and, a number of factors were implicated in this. They felt protected – particularly from the pressure of accountability, gained support from the physical presence of a preceptor or senior member of staff, and were able to benefit from being guided in order to develop their knowledge, skills and confidence. This period therefore appeared to act as a buffer against the detrimental reactions experienced by other newly qualified nurses described by Kramer (1974), Gerrish (2000), Whitehead, (2001), and Boychuk Duchscher (2007).

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Significantly, the participants also compared their experiences favourably with their colleagues who were working in acute care settings, as Tyler illustrated:

“From speaking to some of my friends who have been dumped right into the deep end basically and left to it, I’m glad, because I’d rather have somebody there for support and do things right than to be left to my own devices and do something wrong”.

By describing colleagues in the acute clinical setting as “being dumped into the deep end” and “left to it” implies that they received little, if any support. The use of such idioms have been reported repeatedly to describe the feelings of newly qualified nurses during the initial stage of the transition process in acute settings, for example both Dearmun (1997) and Amos (2001) reported that nurses felt as though they were “thrown in at the deep end”. Ellerton and Gregor (2003) described “surviving” and “just holding my head above the water”. In comparison, the participants in this study did not use such expressions, indicating that this was not their experience. Rather, they acknowledged that the model of supervision used in the community served to protect them from over exposure or lack of support in clinical situations which created a safety net in the event of mistakes. The participants saw their supervisors’ presence as a benefit, protecting them from being put in a position beyond their competence. This mirrors Lauder et al’s.,(2008) findings that new graduates are aware that they need high levels of support and that newly qualified practitioners working in the community reported greater satisfaction with all the sources of support compared to those working in acute settings. That said, it is difficult to ascertain the optimum amount of time that newly qualified nurses should spend in the physical presence of a preceptor or mentor. It is fair to suggest that for many newly qualified nurses, the preceptorship period may be cut short due to competing work pressures. For example a review by Hancock (2002) found that the 4 week supernumerary period recommendation in a preceptorship programme for

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neonatal nurses (NMC, 2006) was not always completed due to lack of availability and time commitments of qualified staff. Furthermore, this is often a cause for disappointment amongst newly qualified staff (Robinson & Griffiths 2009). The findings reported here contest this and they present a significant challenge to established assumptions that community teams, including children’s community nursing teams, have insufficient staff and time to adequately supervise newly qualified nurses appointed to posts in the community as first post destinations.

However, the participants did not always find this helpful, and as noted by Tyler the presence of a qualified nurse during the shadowing period was at times unwelcome and perceived as unwanted surveillance;

“But when I first started it was literally there was somebody over your shoulder, observing you, which is good, but it didn’t do much for my confidence, I’ll be honest. So at first, it was frustrating, because the things that I could do, it was like they were there all the time, looking over my shoulder, but I am glad of it now. Stuff like the asthma where I felt very confident to do, because I was very protected and people were very worried because I was on my own and then I don’t work, I’m a lot more relaxed doing stuff on my own, whereas I think if someone’s watching over me, I do become a little bit paranoid and I start stammering and doing things wrong because I’m thinking, I become very nervous.”

It seems that Tyler understood the benefits of the system but that this also had other implication for her developing confidence. Whilst feeling perfectly capable and confident to undertake some aspects of care on her own, she interpreted the surveillance by other team members as a signal indicating a lack of confidence in her ability. It is possible that this could have disrupted her progress towards moving to the next stage of transition.

Furthermore, whilst some of the participants reported the benefits of spending most of the time with the same preceptor, not all the participants valued the support of just one person

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in the shadowing period. For example Chris thought this was a limitation to her development. She thought it could have been of more benefit to spend more time with other members of the team.

“I think you’d get a better picture of just different practice as well and you wouldn’t feel like I said you’re just regurgitating everything”.

Consequently observing different styles of practice and how a variety of people delivered nursing care was viewed as being helpful in learning to develop their own practice. The participants interpreted their experiences such that they viewed working with different nurses as positive as it gave them a variety of models of practice. They also viewed being restricted to working with a single nurse as a risk. Which they viewed as problematic. It is clear from the data that the shadowing period was a time during their transition that involved close working with another, more experienced nurse. The participants recognised and described this part of their transition as a period of movement between supported, observed practice, to more independent working. They felt “protected” from over exposure to potentially difficult experiences in clinical practice or positions beyond their competence. However, this was also experienced as unwelcome surveillance, or being “watched” which, although understood to be a necessary part of the process, led to feelings of frustration, evoking a lack of confidence which may have disrupted their transition.

Although the benefits of supervised practice have been well documented, it may be that the fine detail of the experience, that is, the feelings of the participants undergoing this could be explored further.

The analysis had led me to consider the notion of an “ideal” model of supervision for this stage of transition. It could be argued that some aspects of this ideal experience of transition

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are already well known, such as the importance of the physical presence of a preceptor, which affords protection, and to be supernumerary to learn about the job before being placed in a position beyond individuals’ perceived competence. However there should also be some acknowledgement that this stage may also involve less facilitative factors such as feelings of being watched which may serve to reduce or impact on the development of confidence and inhibit a smooth transition process. This suggests that any ideal experience of transition would need to take account of individual difference, differences in the interpretation of similar experiences and that individuals may move at different time scales. Furthermore, it may be that the ideal experience of transition involves the opportunity to observe more than one qualified nurse during this time as this was perceived as facilitative by the participants in this study. Observing the practice of different children’s community nurses delivering care was valued and understood to be an advantage in the development of the practitioners practice as they had seen things from more than one perspective.

4.3 “Starting from Scratch”

A further difficulty experienced by the participants in this initial period was the lack of recognition of their previous experience gained during their undergraduate nurse education by members of the children’s community nursing team. As Chris described:

“It’s almost like putting down what I have achieved in three years at University to starting from scratch in community and not really being seen as being able to do anything really. I’d say it was more of you’re in your third year being a student you’re happy, you’re confident you’re seen as the top level of being a student and then once you’ve gone into being a nurse you’re sort of back at the bottom it tends to be more of a negative thing … that you’re the newly qualified, and it is talked about in like a negative tone. I think as well you’ve done like a year and a half before you’ve even qualified of nursing experience. I think a lot of people forget that when you go into your first job depending how much you put into your nurse training depends on how much you know and competence”.

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Although positive and confident about her skills Chris felt that the team saw her as just a newly qualified nurse, failing to recognise her strengths or previous experiences which meant that she had to “start from scratch”. Chris realised that there was a difference between her perceptions of what it meant to be newly qualified and what this meant to others. It seemed to Chris that team members equated being newly qualified with a lack of experience rather than recognising the value of the experience of undergraduate nurse education. In part, Chris had gone through a change in status that involved moving from being at the top level as a student to now being perceived to be back at the bottom by her colleagues.

She not only recognised the change in status but experienced this change as a negative factor and attributed this to the lack of acknowledgment of her undergraduate community experience by established staff. Boychuk Duchscher (2007) and more recently Farasat (2011) highlighted the importance to newly qualified nurses of being valued by others in the clinical environment and that this can have a positive impact on confidence levels. They suggested that newly qualified nurses anticipate the fulfilment of being recognised for the knowledge and experience they have acquired during their undergraduate nurse education. What Chris illustrates is not only that the experience of starting from scratch disrupted her perceptions of the status that she thought she would be afforded at this stage, it illustrated that qualified staff attitudes to this were disrupting her transition.

Chris recognised that she was in a liminal state, which van Gennep (1960) and Turner (1988) describe as being on the threshold or margins. Being in this state during this stage can produce feelings of isolation and disruption to an individual. Indeed the acceptance of

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the newly qualified nurse is thought to be a pivotal aspect of their developmental need to assimilate into the existing group (Boychuk Duchscher and Cowin, 2004). The perceived

lack of acceptance of newly qualified nurses by their new group of colleagues may lead to marginalization (Boychuk Duchscher and Cowin, 2004) with newly qualified nurses on the periphery of the dominant group of seasoned nurses with whom they work. The idea of being placed on the periphery of the dominant group has been explored in the theoretical explanations of transition as marginalization (e.g. Meleis el al., 2000; Boychuk Duchscher 2007) and is thought to be a condition that may inhibit transition. The term marginal man

was originally coined by Park in 1928 to describe the assimilation of migrants into the dominant culture or as living between two cultures that have asymmetrical power. The concept was expanded in relation to transition to include the process through which persons are placed on the periphery on the basis of identities, associations, experiences and environments (Hall, Stevens & Meleis 1994). Boychuk Duchscher & Cowin (2004) applied the concept to newly qualified nurses and highlighted the perceived lack of acceptance by them into their new group. As van Gennep (1960) suggests, strangers need to be let into the group, and this is key for these newly qualified nurses because they desire the acceptance, respect and admiration of colleagues.

One of the main indicators that an individual has completed the transition stage is reformulation of their new identity and status (van Gennep 1960, Meleis et al., 2000). In the case of the participants in this study entering the group and being afforded the status of being a children’s community nurses has traditionally depended on being seen as having some post qualifying experience prior to entering the community. Entering the community as a newly qualified nurse troubles this tradition and disrupts the perceptions of the team in

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relation to their status, this in turn hindered the participants’ development of their identity as children’s community nurses. Here, Tyler illustrates how being “newly qualified” was perceived by other members of the children’s community nursing team in a fairly negative way:

“But when you are seen as newly qualified not from all of the staff but from some of the staff, well, what some members of staff did say to me is that they didn’t agree with newly qualifieds in the community because they hadn’t had previous experience”.

Being newly qualified in this context was linked by the team to the participants’ lack of experience and therefore lack of ability to act independently, which they may have perceived as reducing their value as a team member. In contrast, the participants valued their experience as student nurses not least because they had undertaken several placements within a community setting with health visitors, school health advisors and children’s community nursing teams during their undergraduate nurse education. For example during