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Early Socialization of New Critical Care Nurses

	Abstract

Top Abstract Background Literature Method Results Navigating the Challenge Discussion and Implications Study Limitations Conclusion References

 
• Background Critical care nurses provide care to acutely ill patients, yet little is known about the early socialization processes of new nurses to critical care units from the nurses’ perspectives.

• Objectives To explore the early socialization processes of critical care nurses.

• Methods A grounded theory design was used to generate a local theory of how critical care nurses experience socialization. Interviews and journals of participants (N = 10) during the first 4 to 5 months of the socialization experiences were collected. Preceptors were interviewed to triangulate data. Orientation materials and field notes were examined.

• Results A process of 5 phases was uncovered: the prodrome, welcome to the unit, disengagement/testing, on my own, and reconciliation. Participants experienced difficulty while being evaluated by preceptors early in the orientation process because of changing expectations. Participants also expressed disappointment in their level of comfort at the end of the orientation. The theory termed "navigating the challenge" explains the nature of the changing expectations that new critical care nurses face during their socialization process.

• Conclusions This exploratory study defines the phases that new critical care nurses experience during the early socialization process. Phase-specific recommendations are made on the basis of the results of the study.

Although specialty areas prefer experienced nurses, graduate nurses do enter critical care. Cardona and Bernreuter¹ acknowledged the need to use graduate nurses in critical care and made recommendations for a cost analysis of overhiring graduate nurses. The need to hire graduate nurses into specialty areas during nursing shortages is well known.^3–5 With nurses entering critical care areas with various skill levels, it is important to know how nurses with various levels of experience are socialized to critical care.

In order to understand how socialization occurs, the process that new critical care nurses currently navigate as a part of the socialization experience must be determined and analyzed. Therefore, the focus of this study was the following question: What are the early socialization processes of new critical care nurses? For the purposes of the study, socialization was defined as "the process by which persons acquire the knowledge, skills, and dispositions that make them more or less able members of their society."⁶ This definition is most appropriate for this study because it encompasses skills needed for technical role socialization, and it includes the affective domain of socialization. The outcome of the study is to develop a local theory on the socialization experience of new critical care nurses in an effort to understand and improve upon the socialization process.

	Background Literature

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Seminal works by Kramer⁷ and Benner⁸ describe the experiences of nurses as the nurses move from one area or level of practice to the next. In particular, Kramer delineates 4 phases of reality shock and their implications for new nurses. Although Kramer finds that new graduates are at the highest risk for reality shock, she cautions that experienced nurses may experience reality shock when making a transition to a different area of practice.⁷ Kramer’s work has led to the development of orientation programs that emphasize to preceptors the importance of recognizing and intervening during different phases of reality shock.⁹

Benner⁸ describes transitions that new nurses make in terms of the abilities the nurses demonstrate in clinical practice. The 5 stages, from novice to expert, detail what the capabilities of the nurse are at each level. Benner provides a detailed analysis of the competencies expected at each level of practice.

Boyle et al¹⁰ investigated socialization of new graduates into critical care with respect to congruence with a modified contingency theory and recommended that attention be paid to positive preceptorial experiences, support systems, and congruence of assignments across each phase of the socialization experience.

Much has been published on selected aspects of the socialization experience for new nurses. For example, published reports support multiple approaches to facilitate critical thinking,^11–13 address the importance of implementing adult learning principles,^14,15 and consider the variables attributable to role transition.^16,17 No studies, however, have considered a holistic approach that includes the affective domain of socialization in critical care units. Further, no published study has addressed the socialization of new critical care nurses, across all levels of experience, in an open-ended, participant-driven approach. Understanding what occurs during the orientation process from the participants’ perspectives elucidates how the process is perceived by the participants and provides the information needed to design interventions for critical points during the process.

	Method

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Grounded theory methods were used to answer the research question. Grounded theory provides techniques for an inductive inquiry leading to the development of a substantive, local theory.¹⁸

After approval was granted by the university’s institutional review board and by the study sites, participants were recruited through hospital and unit educators from the central and south central portions of Indiana. The inclusion criteria were that the participant had to be a registered nurse new to an adult critical care area and had to be in the first month of orientation to critical care. A purposive sampling technique was used to secure participants from multiple sites and critical care units. I directly recruited participants by attending hospital orientation sessions.

Data collection and data analysis were done simultaneously by using constant comparative analysis.¹⁸ Consistent with these procedures, data were coded, themes were developed, and data were subsequently reduced. Finally, the socialization process, core variable, and theory were developed to add meaning and context to the themes.

According to Glaser and Strauss,¹⁸ recruitment of participants can be terminated when data become redundant, themes are saturated, and negative case analysis is completed. In this study, data redundancy began with the seventh participant, and theme saturation occurred between the seventh and ninth participants. However, because 2 participants left the critical care unit in the middle of the study, a 10th participant was recruited. The demographic characteristics of the participants are given in Table 1.

Trustworthiness criteria, as outlined by Lincoln and Guba,¹⁹ were met. These criteria include credibility, transferability, dependability, and confirmability. The evidence for each trustworthiness criterion is shown in Table 2.

	Results

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Probably the first thing was, I always remember my first semester of clinicals. . . . I was amazed at how much they [the nurses] knew. . .

I wanted to work critical care for the excitement, challenge, and prestige. According to society, critical care nurses are the best nurses, and I want to be the best.

Participants recognized the seriousness and complexity of caring for critical care patients and felt discomfort about the prospect of being responsible for these patients. Despite these feelings during this phase, new nurses were eager, much like soldiers going into battle. This category was termed up for the challenge.

I’m scared to death. But I think I’ll be a really good nurse when I finish.

I feel I have been given a tremendous challenge, and I’m going to meet it.

Welcome to the Unit
The new nurses often started their socialization process with some initial courses provided by critical care nurse educators, then moved to the unit where they began caring for patients with preceptors. This period was marked by warmth and support for the new nurse. Participants began to describe their experiences with the preceptors as "being nurtured." The level of nurturing varied from one participant-preceptor dyad to the next but usually included words of encouragement and attempts to alleviate fears.

She [my preceptor] keeps telling me that I’m showing some of the same qualities she has. . . . She always reassures me that I’m moving in the right direction.

I was amazed . . . that the first day we had that patient go bad and it was like 4 nurses in the room. They each knew what they had to do and you’re not alone . . . .

In a couple of instances, participants expected more nurturing.

. . . and I really didn’t think she should be leaving me alone that much . . . I mean, I feel like I’m on my own too early.

From what I’ve spoken with the other nurses . . . their preceptors the first 2 and 3 weeks were right there, you know, during the assessment, the vital signs. Every detail, they were there and they were gradually leaving them alone.

Disengagement/Testing
The disengagement/testing phase consists of 3 categories: (1) cutting it, (2) why am I here? and (3) taking charge. Marking this stressful phase was the disengagement or withdrawal of intense support and monitoring by the preceptor.

As participants progressed, they were left to function more independently, reflecting a critical change in their relationships with their preceptors. In addition, new nurses understood that they were also being evaluated on their abilities to deliver key components of basic nursing care. The capability to deliver these key components determined whether or not the new nurse could "cut it," a term used by both participants and preceptors alike. To better understand this category, preceptors were asked what they considered to be components of cutting it.

My job as a preceptor is to make sure they’re [new nurses] getting what they need and doing what they’re supposed to do. They will soon be off orientation and need to know what it’s like before they don’t have me around. . . . They have to be able to organize and figure out what they’re going to do with the patients. They also have to be able to prioritize.

I’m looking for problem-solving skills and for them to move away from such a task orientation. . . . I want them to show intelligence, be able to make quick decisions, be organized, and stand on their own two feet.

My red flags are if they are too confident, don’t look up meds, are providing unsafe care, missing important data, or lack motivation.

This testing environment led to participants’ questioning their ability and confidence. In some instances, participants contemplated leaving critical care for another position.

[Be]cause I forgot to check somebody’s blood sugar and I got really upset . . . for awhile there I said, "Well, I’m not going to do critical care anymore. I’m not even going to stay in the hospital."

It was just like, "What did I get myself into?". . . a patient went bad and we’re going to CAT scan stat. God, the patient had hemorrhaged, they were intubating . . . all this stuff was happening and I was just in the corner.

Although the participants at times felt despondent, they managed to gain control of their experience. Taking control and creating order were achieved by seeking out what they needed to learn (ie, protocols), taking custody of the orientation manual, independently scheduling additional learning experiences, or seeking advice from other nurses.

And I came back out with a stack this big . . . I didn’t even know that all this stuff was in there. . . . So I’ve got all those at home and I’ve been reading through those.

I have an orientation handbook and [my preceptor] is supposed to be initialing everything I did. But I’ve been going home and highlighting everything that I’ve done, but she hasn’t checked off.

All participants progressed to this point, although 2 participants experienced more difficulty than others. I thought that once the participants began to take control, their socialization would be successful. However, the preceptors for these 2 participants thought the participants lacked the skills described in the cutting-it phase, and after conferences with their preceptors and managers, the 2 participants agreed to leave the critical care area.

On My Own
In the on-my-own phase, marked by breaking ties with preceptors, new nurses began to assume more responsibility by taking their own case loads. This break typically occurred between 6 and 10 weeks after each new nurse’s start date. Although formal relationships with preceptors were dissolved, new nurses often did not have full responsibility for patients. For example, some new nurses were still not comfortable with electrocardiographic interpretations, pulmonary artery catheters, intracranial pressure monitors, titration of intravenous infusions of medication, and codes. Staff nurses were expected to assist new nurses with these skills. Key to the next step in the socialization process was being able to take all the data available from the patient and see "the whole picture." Participants referred to this capability as putting it together, which is the main category in the on-my-own phase of the socialization process.

Components of the putting-it-together category make up another skill set and level of goal attainment for new nurses—similar to that of the cutting-it category, but at a higher cognitive level than that category. New nurses described the major markers of putting it together as being able to know what they needed to assess in their patients and making the appropriate care decisions based on knowledge of the patients’ problems.

New nurses were still uncomfortable at this stage, and many of them were disappointed. Although the new nurses had successfully progressed in their orientation sequence, they had expected to feel more capable than they were feeling. Several new nurses described an expectation that by this point in the process they would know more than they did and be more comfortable than they were.

I can’t believe how uncomfortable I still feel. It’s been about a month since I’ve started actually working on this unit. I can feel my whole body tense up as soon as I come on the unit in the morning.

I think it’s going to take me awhile. I really thought that I’d feel more comfortable at this point, and I think it’s going to take a little while longer than I expected. I’m a little disappointed in myself because . . . I thought I was doing well at the end of orientation. That’s because I have that crutch there (the preceptor) . . . so, I am a little disappointed, but I know I’ll get through it.

Reconciliation
Realizing their unmet expectations, new nurses attempted to determine if their feelings were similar to those of other nurses on the unit. To their relief, they found that most of their peers had not felt comfortable until 6 months to 1 year after the start of their critical care careers. New nurses received support from their peers and were counseled that the keys to becoming more comfortable were time and experience in caring for patients. These messages were encouraging because new nurses realized that they still had much to learn, but they had passed the most difficult part.

She [my preceptor] told me it would take me about a year to . . . start feeling comfortable. Which sounds like a really long time, but she said it goes pretty fast. So she says that what I’m feeling is normal or at least that’s how she felt.

I still have a long way to go, but I think I have (made it). Personally overcoming the fear that I wouldn’t be able to stay was important.

Reflection on the socialization experience took place in this phase. New nurses identified the areas of the process they thought could have been facilitated better, as well as those experiences that were most valuable. New nurses also specified persons they thought could take them to the next level of practice. In some instances, this person was the nurse’s preceptor, but in other instances, it was another nurse on the unit. New nurses appeared to be setting up an informal mentoring situation and expressed the need to set new goals to improve their practice.

Am I a Critical Care Nurse?
During the last interview, new nurses were asked questions to determine whether they felt like they were critical care nurses. This question was asked to gauge the extent to which socialization, from the participants’ perspective, was complete. The main question was, When people ask you what you do, what do you tell them? The following are some of the responses.

I am a nurse.

I tell people who ask, that I’m a critical care nurse.

I say I’m a nurse.

Two of the new nurses quickly identified themselves as critical care nurses, but most others hedged. Some nurses thought their response to the question depended on who asked the question in terms of the person’s knowledge about nursing specialties. With this information, a generalization cannot be made concerning the extent of the socialization process. It appears that new nurses may have different thresholds for when they would identify themselves as critical care nurses.

	Navigating the Challenge

Top Abstract Background Literature Method Results Navigating the Challenge Discussion and Implications Study Limitations Conclusion References

 
The hallmark of a grounded theory study is identification of a core variable and the theory applicable to the participants under study. The core variable and local theory generated from the data were termed navigating the challenge. The theory reflects the strong internal process that occurs in the phenomenon of socialization of critical care nurses—especially the changing expectations from phase to phase. Although new nurses used a variety of external cues, those cues were important only in how they were related to individual progress toward socialization.

In each phase of the socialization process, new nurses had to determine what expectations were being held of them and then had to devise a plan to meet those expectations. Early on, the expectation was set by the new nurses, but as the orientation and evaluation program progressed, expectations came from a range of people: preceptors, nurse managers, nurse educators, physicians, and other staff. In some instances, the expectations were clearly stated, such as attainment of skill proficiency. However, in other situations, the expectations were less apparent, such as in the disengagement/testing phase. When preceptors say they are going to "step back" to see how the new nurse is performing after a few weeks, a gray area is entered. This gray area is much different from the nurturing that occurred just a week before this phase. From this point, new nurses must realize that they are responsible for setting these learning goals by asking themselves, Where do I need to be? and How am I going to get there? In this situation, new nurses are forced to be more attuned to external cues, sometimes subtle cues that direct them on how to stay on course. New nurses begin to triangulate the cues in order to assimilate them into a successful venture.

	Discussion and Implications

Top Abstract Background Literature Method Results Navigating the Challenge Discussion and Implications Study Limitations Conclusion References

 
My findings lend support to the conceptual frameworks described by Kramer⁷ and Benner.⁸ The phases of the socialization in all nurses who are new to critical care, not just new graduates, are similar to the phases of reality shock described by Kramer. In addition, Kramer’s assertion⁷ that both experienced nurses and new graduates experience reality shock when changing their practice arena is substantiated by my study on new critical care nurses.

Kramer’s honeymoon phase is similar to the prodrome and welcome-to-the-unit phases in this study. Both phases mark a time when new nurses are enthusiastic about their new positions and look forward to meeting the hefty expectations they have set for themselves. The phase is marked by staff introductions and a general overview of the unit. The preceptor role is that of a nurturer.⁷

The shock phase in Kramer’s work is consistent with the disengagement/testing phase in my study. New nurses experience less nurturing from preceptors and often feel overwhelmed. They also begin to realize that many obstacles must be overcome to attain their goals. This phase is often the time when new nurses contemplate leaving their positions.⁷

Whereas Kramer’s next phases are those of recovery and reconciliation, and those phases are similar to this study’s reconciliation phase, participants in my study moved through the on-my-own phase. This phase diverges from Kramer’s conceptualization⁷ and is important because it is the phase in which the formal orientation period ends but socialization continues. The phase is very focused on skill and knowledge acquisition as new nurses strive, once again, to move from novice status. It is a work-intensive phase that creates the gateway to the final reconciliation phase.

Another difference between my study and Kramer’s study⁷ is that the initiating factors for each phase are not considered. In my study, the structure of the orientation programs drove movement from one phase to the next. For example, after preceptors spent the first part of the orientation period teaching and acclimating new nurses to unit surroundings, the preceptors quickly moved to an evaluative role with less emphasis on teaching. New nurses also had less access to their preceptors during this period as the new nurses sought to find their own organizational strategies. This change, initiated by preceptors and the orientation program, is the antecedent to the uncomfortable phase of disengagement/testing. The change in the relationship is a key force in how new nurses move through the phases.

The new critical care nurses found that their aspirations to move from novice to expert by the end of the orientation period were unrealistic. Participants recognized that the ability to "put it together" was something that was acquired with time and experience. Consistent with Benner’s work,⁸ the participants realized that they had much to learn at the end of the orientation and began identifying nurses they saw as expert in order to meet the next stages in role development.

Despite Alspach’s call for consistency in formal orientation programs,²⁰ Thomka¹⁷ found a lack of consistency in the way graduate nurses were assisted through their socialization experiences, particularly in their relationships with preceptors. The results of my study make it possible to make recommendations for facilitating new nurses through each phase of the process (Table 4).

	Study Limitations

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Another limitation of my study was that the participants were all from a midwestern state. Although care was taken to recruit participants from a variety of institutions within the region, all participants were from a single state. Orientation programs in the region may differ from those in other regions, and these differences could affect the socialization process. Future research should be directed toward recruiting participants across multiple geographic areas. In addition, because this study’s major aim was to explore the early socialization process, more investigation must be done to explore later experiences.

	Conclusion

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Socialization to critical care is an important phenomenon to understand not only in terms of administrative implications but also in terms of implications for patients’ care. By exposing the socialization process by following nurses as they are experiencing the process, we become more aware of the conflicts, decision making, and challenges faced by new critical care nurses. On the basis of this study, the socialization process for new critical care nurses can be improved upon with the ultimate goal of improving patients’ care.

	ACKNOWLEDGMENTS

 
This research was supported by a grant through Indiana University School of Nursing. I thank Dr Sherry Sims and Phyllis Dexter for their assistance in the preparation of this manuscript.

To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.

	REFERENCES

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