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 Chapter 2: The Costs and Consequences of Incivility i

The Nurse’s
Reality Gap
Overcoming
Barriers Between
Academic Achievement
and Clinical Success
Leslie Neal-Boylan,
PhD, CRRN, APRN-BC, FNP
ii The Nurse’s Reality Gap
Copyright © 2013 by Leslie Neal-Boylan
All rights reserved. This book is protected by copyright. No part of it may be reproduced,
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trademarks, service marks, design rights, or similar rights that are mentioned, used, or cited in
this book are the property of their respective owners. Their use here does not imply that you may
use them for similar or any other purpose.
The Honor Society of Nursing, Sigma Theta Tau International (STTI) is a nonprofit
organization whose mission is to support the learning, knowledge and professional
development of nurses committed to making a difference in health worldwide. Founded in
1922, STTI has more than 130,000 active members in more than 85 countries. Members
include practicing nurses, instructors, researchers, policymakers, entrepreneurs and
others. STTI’s 486 chapters are located at 662 institutions of higher education throughout
Australia, Botswana, Brazil, Canada, Colombia, England, Ghana, Hong Kong, Japan,
Kenya, Malawi, Mexico, the Netherlands, Pakistan, Singapore, South Africa, South Korea,
Swaziland, Sweden, Taiwan, Tanzania, the United States, and Wales. More information
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To order additional books, buy in bulk, or order for corporate use, contact Nursing Knowledge
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ISBN: 9781937554460
EPUB ISBN: 9781937554477
PDF ISBN: 9781937554484
MOBI ISBN: 9781937554491
__________________________________________________________
Library of Congress Cataloging-in-Publication Data

Neal-Boylan, Leslie.
The nurse’s reality gap : overcoming barriers between academic achievement and clinical success
/ Leslie Neal-Boylan.
p. ; cm.
ISBN 978-1-937554-46-0 (book : alk. paper) -- ISBN 978-1-937554-47-7 (ePUB) -- ISBN 978-
1- 937554-48-4 (pdf) -- ISBN 978-1-937554-49-1 (mobi)
I. Sigma Theta Tau International. II. Title.
[DNLM: 1. Nurse’s Role. 2. Clinical Competence. 3. Education, Nursing. 4. Job Satisfaction. 5.
Nurses--supply & distribution. 6. Personnel Management. WY 87]

610.73--dc23
2012047799
__________________________________________________________
First Printing, 2013
Publisher: Renee Wilmeth Principal Book Editor: Carla Hall
Acquisitions Editor: Emily Hatch Content & Project Editor: Kate Shoup
Editorial Coordinator: Paula Jeffers Assistant Editor: Jennifer Lynn
Cover Designer: Michael Tanamachi Proofreader: Barbara Bennett
Interior Design/Page Layout: Katy Bodenmiller Indexer: Jane Palmer
 Chapter 2: The Costs and Consequences of Incivility iii

Dedication
To my dad, Edward Rotkoff (the “blond tiger”), and my children, Paul,
Cori, Andy, and Bonnie, with lots of love.
iv The Nurse’s Reality Gap

Acknowledgments
I would like to thank all of the nurses who responded to the survey and
shared their insights and experiences for the purposes of this book. It has
been a pleasure and an honor to work with the excellent editorial staff at
Sigma Theta Tau International. I would also like to thank Claryn Spies for
her generous assistance with this project.
 Chapter 2: The Costs and Consequences of Incivility v

About the Author

Leslie Neal-Boylan, PhD, CRRN, APRN-BC, FNP

Leslie Neal-Boylan is associate dean and professor at Quinnipiac

University in Hamden, Connecticut. She earned her BSN from Rutgers
University, her MSN from San Jose State University, and her PhD in
nursing from George Mason University. She received a postmaster’s
certificate as a family nurse practitioner (FNP) from Marymount
University. She is a board-certified family nurse practitioner and is certified
in rehabilitation nursing, home health nursing, and rheumatology. She
maintains a clinical practice as an FNP. Neal-Boylan has more than 30
years of direct clinical experience and 15 years in nursing education. She
has held various leadership positions in nursing throughout the years.
She has authored and/or edited almost 100 peer-reviewed publications,
including seven books. Neal-Boylan’s research focus has been on the
nursing workforce, most recently concerning registered nurses with
disabilities and retired volunteer nurses. However, she has also published
on topics related to geriatric patient care, the nurse practitioner role, and
chronic illness.
vi The Nurse’s Reality Gap
 Chapter 2: The Costs and Consequences of Incivility vii

Table of Contents
About the Author. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Introduction.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

1 The Associate Degree-Prepared Nurse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Preparation.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Nursing Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Time Management and Documentation. . . . . . . . . . . . . . . . . . . . . . . . 6
Clinical Experience. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Leadership and Delegation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
The BSN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Barriers and Challenges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Limited Employment Opportunities. . . . . . . . . . . . . . . . . . . . . . . . . . 10
Transitioning From Student to Nurse.. . . . . . . . . . . . . . . . . . . . . . . . 11
Time Management.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Lack of Professional Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Day-to-Day Work.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Politics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Facilitators. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

2 Life As an ADN-Prepared Nurse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Orientation to the Role. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Preceptors and Mentors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Peers and Colleagues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Communicating With Physicians and Staff.. . . . . . . . . . . . . . . . . . . . . . . 24
Role Change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
The Meaning of Nursing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Advice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
viii The Nurse’s Reality Gap

3 The Bachelor’s-Prepared Nurse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Preparation.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Nursing Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Clinical Experience. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
CNA Experience. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Leadership and Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Depth of Learning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Higher Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Barriers and Challenges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Limited Employment Opportunities. . . . . . . . . . . . . . . . . . . . . . . . . . 47
Transitioning From Student to Nurse.. . . . . . . . . . . . . . . . . . . . . . . . 48
Time Management.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Lack of Professional Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
The Learning Curve. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
The Work Environment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Coping With Patient Illness and Unhappiness. . . . . . . . . . . . . . . 54
Facilitators. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

4 Life As a BSN-Prepared Nurse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Orientation to the Role. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Communicating With Physicians and Staff.. . . . . . . . . . . . . . . . . . . . . . . 63
Role Change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
The Meaning of Nursing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Advice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

5 Graduate Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Preparation.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Nursing Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
 Table of Contents ix

Barriers and Challenges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Adjusting to a Leadership Role. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Lack of Business Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Getting Published. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Facilitators. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Orientation.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Communicating With Physicians and Staff.. . . . . . . . . . . . . . . . . . . . . . . 99
Role Change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
The Meaning of Nursing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Advice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

6 The Chasm in Nursing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

What Is Nursing?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
The Chasm in Academia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
The Chasm in Professional Journals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
The Chasm in Nursing Organizations and Societies. . . . . . . . . . . . 117
The Chasm in Professional Conferences. . . . . . . . . . . . . . . . . . . . . . . . . . 118
Bridging the Chasm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

7 Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Getting a Job.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Clinical Experience. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Communication Skills. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Orientation.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Behavior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Paperwork. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
To the New Nurse Graduate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
To the New Master’s-Prepared Graduate. . . . . . . . . . . . . . . . . . . . . . . . . 136
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
x The Nurse’s Reality Gap
 Chapter 2: The Costs and Consequences of Incivility xi

Preface
When I first set out to write this book, my objective was to discover
how it felt to be newly graduated as a registered nurse. This book
was originally envisioned as a way to share the experiences of nurses
transitioning from student to professional. My hope was that new
graduates could read about the experiences of their peers and perhaps
circumvent the difficulties that had arisen for their predecessors. I knew
that nursing had changed in many ways since I graduated in 1981; some
changes were clearly for the better, but other changes concerned me. I
knew anecdotally and from articles and professional conversations that
many nurses, especially recently graduated nurses, were and are leaving
nursing. I come from a long line of nurses, and I love being a nurse, so I
despair that there will be fewer enthusiastic nurses to take my place when
I become too old to do what I love.

I did not intend to conduct a formal research study. I just wanted

to get a general sense of how recently graduated nurses felt about
being nurses. I also realized that very little had been done to explore
the experiences of nurses who recently completed graduate degrees. I
determined that an online survey could be the perfect vehicle for obtaining
this information. To gather this information, an assistant and I sent
announcements and the link to the online survey to 180 nursing schools
and 50 student nurse associations. We also distributed the announcement
at nursing conferences. The assistant helped me to collate and organize the
responses.

The original idea was to obtain responses from graduates of diploma,

associate, baccalaureate, master’s, and doctoral degree programs. We
received slightly fewer than 100 responses—none from diploma graduates
and only a few from doctoral graduates. The rest were approximately
evenly divided.

Any good researcher would cast doubt on the validity of information

gleaned from 100 responses, especially when those responses are divided
into three groups. Keep in mind, however, that most responses from
associate-degree graduates are very consistent with those of baccalaureate-
degree graduates. In addition, master’s-prepared graduates have
xii The Nurse’s Reality Gap

heretofore been an underrepresented group with regard to new graduate

experiences. If I had it to do over again, I would design a formal research
study—something I still think is worth pursuing, especially in light of the
interesting responses I received.

I realized as I read through the responses that not only would they be
helpful for nursing students and other new graduates, but they would also
inform nurse educators and leaders about how recent graduates feel about
nursing and their preparation to enter the profession. The book morphed
into a discussion about what is right and wrong in nursing and what we
might need to fix as we move into the future.

There is no substitute for formal and rigorous research methods

to gather sufficient high-quality data from which to draw reliable and
valid conclusions. However, the responses gleaned from this more casual
survey are valuable nonetheless, because they provide a window into how
new graduates feel. Moreover, their experiences confirm much of what
is already in the literature. One might fairly say that only people with
complaints respond to informal surveys. It is interesting to note, though,
that many positive comments came through from the survey, and the
responses give us many reasons to be proud of our profession and of our
graduates.

I would also like to say a word about the integration of my own

perceptions in the book. After being in nursing for more than 30 years in a
variety of professional settings and positions, I feel that I have earned the
right to reflect on my own observations about nursing and to comment on
what I think we do well and what we could do better. Some readers will
find similarities between my perceptions and their own. Others may think
me harsh and that my thoughts don’t apply to them or their experiences
in nursing. In that case, I’d be relieved that my experiences may not be as
pervasive as I think. I encourage nurses, regardless of their perspectives,
to open up or continue a dialogue about what is working and what is not.
Clearly, the exodus of nurses can only be interpreted as catastrophic to the
profession. Let’s work together to strengthen what is working and to fix
what is not.

–Leslie Neal-Boylan
 Foreward xiii

Foreword
In The Nurse’s Reality Gap: Overcoming Barriers Between Academic
Achievement and Clinical Success, Leslie Neal-Boylan presents a thorough
assessment of the work of new nurses and gets at the crux of the issues
of retention and burnout: the meaningfulness of nurses’ work lives.
While there is much in the literature identifying specific factors leading
to burnout and retention issues, including research and expert opinions,
Neal-Boylan approaches the topic by going directly to nurses for their
thoughts, experiences, and opinions. She also offers very specific tips for
new nurses, summarizing lessons learned from the field. Every new nurse
should carry these tips with them on a smartphone or a note card. The
advice is easy to take for granted but also easy to forget when nurses are
caught up in day-to-day work. Mentorship, for example, is critical, as are
asking questions and networking with other nurses to ease the transition
from the academic world to clinical work.

A unique and important feature of this book is the inclusion of

content about newly prepared graduate-level nurses, including those with
doctorates. An often-overlooked group, these nurses also face challenges
transitioning into new roles, and some of the same strategies can be useful
for brand-new nurses and those making major professional changes. I
have personally had the advantage of having the same professional mentor
throughout my career, a nurse in whom I have the utmost trust. I value
her opinion on any issue and have sought her advice routinely. Before the
time of instant communication, I knew that I could make a collect call to
her from anywhere in the world. Every nurse should have a mentor who
will be available for advice, support, coaching, and care. This message is
communicated loud and clear in the voices of the nurses throughout this
book.

There are many important lessons in the words of the nurses

represented here. Nurse educators and nurse leaders in health care
facilities are reminded of the need to build and implement support
structures to smooth the transition to new roles. We know that
mentorship and fellowship programs matter, yet not all health care
facilities offer these programs. The added value far outweighs the program
costs, particularly when considering the costs of nurse replacement, which
xiv The Nurse’s Reality Gap

are approximately twice the annual salary of the nurse. For preparation of
nurses at the graduate level, there is an identified need for both education
and management courses. Our health care and educational institutions
would be well served if nurses prepared at the graduate level had these
skills. It is also heartening to note that graduates of these advanced-degree
programs identified a need for more research and publication skills.
The profession will indeed be better served if we enhance our graduate
education and stretch students beyond their comfort zone.

This book is timely, given the recommendations of the 2010 Institute

of Medicine (IOM) Future of Nursing report. Noteworthy is the refrain of
some of the associate degree-prepared nurses that they should have opted
for the baccalaureate degree in the beginning. Other messages from nurses
are also consistent with the IOM report, including the need for more
residency programs and the need to focus on primary and community
care, as demands for acute care are changing.

Without a doubt, the most important contribution of this book is in

capturing the many questions that abound within the nursing profession.
Neal-Boylan raises issues that often have remained dormant in our
intellectual and professional discussions. These issues are important
if we are to restructure our educational and practice programs. More
importantly, many of these unresolved issues lead to the professional
chasms identified by Neal-Boylan. The discussion and debate will be
enhanced through this frank acknowledgement that resolving professional
differences may well be a wise investment in future nursing generations.

–Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN

 Introduction xv

Introduction
The fact is, new nurses are leaving the field of nursing at an alarming
rate (Black, Spetz, & Harrington, 2008, 2010; Wood, 2013). With fewer
nurses, there is a tendency to employ unlicensed personnel and people
who are not as well-educated as RNs to care for patients. The use of
unlicensed personnel, especially, has resulted in fatalities and patient
complications that should not have occurred. Technically, there really is
no shortage of nurses today. There are 3 million nurses in this country.
However, there is a shortage of nursing jobs, because organizations do not
seem to grasp that “you get what you pay for.” That is, it is worthwhile
paying to employ RNs rather than less-educated health care workers,
because RNs improve the quality of patient care, and their work leads to
better patient outcomes. With the ebb and flow of nursing shortages in the
United States, doing everything possible to retain nurses is imperative. To
do this, one must first grasp why nurses leave.

Nurse Retention and the Meaning

of Nursing
Recent years have seen tremendous focus on the issues of nurse retention
and satisfaction. Researchers have identified a variety of factors that
influence nurses’ decisions whether to remain in their jobs and in
nursing. According to a 2009 study by Morgan and Lynn, much of what
provided satisfaction to nurses had to do with the meaning of nursing—in
other words, providing comfort to patients, interacting with them, and
advocating for them.

The researchers found that nurses in the study felt that the nursing
shortage had to do with not having enough help from nurses who
were skilled and experienced enough to address the needs of patients.
Participants in this study put much of the blame on inadequate training or
orientation of new nurses.
xvi The Nurse’s Reality Gap

Note
According to the Morgan and Lynn (2009) study, other keys
to job satisfaction for nurses are the interactions nurses have
with each other and with their patients. Receiving support
from coworkers was particularly significant. However, many
nurses noted that a lack of resources—mostly with regard to
staff—required them to work harder to do the work that was
necessary. Researchers concluded that in addition to extrinsic
rewards such as pay, it is important for nurses to experience
intrinsic satisfaction through their relationships with
coworkers, patients, and other nurses. Nurses also valued
the autonomy they gained as they became more experienced
and enjoyed mentoring less-experienced nurses. (Researchers
described “autonomy” as having control over one’s work
and being able to prioritize work without being closely
supervised.)

Preparing Nurses for the Clinical Setting

The literature abounds with the need to better prepare registered nurses
to practice in a clinical setting. Nursing schools are continually pressured
to add more content to best train new graduates to begin in their roles
as nurses (Ulrich et al., 2010). Another study—this one focusing on new
nurses and their transition into the profession, conducted in 2009 by
the National Council of State Boards of Nursing—demonstrated that
even after 2 and 3 years of practice, nurses still do not feel entirely
comfortable and confident about making clinical decisions, planning
and initiating care, and communicating with physicians (Hoffart,
Waddell, & Young, 2011).
 Introduction xvii

Pertaining to these issues, a 2010 report by the Institute of Medicine,

The Future of Nursing, has established several recommendations:
• Nurses should practice to the full extent of their education
and training.
• Nurses should achieve higher levels of education and training
through an improved education system that promotes seamless
academic progression.
• Nurses should be full partners with physicians and other health
care professionals in redesigning health care in the United States.
• Effective workforce planning and policymaking require better
data collection and an improved information infrastructure.

Improving Nursing Education

On the topic of receiving higher levels of education and training through
an improved education system, the Carnegie study (Benner, Sutphen,
Leonard, & Day, 2010) advocates for the following:
• Nursing must undergo major changes to prepare new nurse
graduates for practicing in the profession.
• There must be significant increases in the number of students
admitted to nursing schools to meet the demand for nurses both
now and in the future.
• Entry-level positions in nursing should require a baccalaureate
degree.
• Baccalaureate-prepared nurses should be encouraged to pursue
graduate degrees, partly to increase the number of nursing fac-
ulty. (Some nurse leaders support the continuation of associate-
degree programs but note that their graduates should be strongly
encouraged to pursue the baccalaureate degree.)
• Clinical courses should be integrated into the curriculum in
the first 2 years of the baccalaureate program. This will both
introduce students to nursing and prepare them for the reality of
community-based nursing by offering more clinical experiences
in settings other than in acute care.
xviii The Nurse’s Reality Gap

Note
The Robert Wood Johnson Quality Safety Education for
Nurses (QSEN) initiative offers resources to help promote
excellence in new nurse graduates, both clinically and in
health care (http://blog.rwjf.org/humancapital/category/
nursing/). Suggestions are available through QSEN for nurse
educators of both undergraduate and graduate students to
help educators teach in ways that promote excellence.

Improving the Workplace

Of course, education is not the only area that needs work, as evidenced
by a qualitative study of nurses in their first year practicing in the hospital
setting (Martin & Wilson, 2011)—a year that has been described by
many authors and researchers as the most difficult in the career of a nurse
(Blanzola, Lindeman, & King, 2004; Casey, Fink, Krugman, & Probst,
2004). Researchers in the Martin and Wilson study were particularly
interested in two themes that appear in the literature: the acculturation of
the professional (Kramer, 1974) and the responsibilities of the professional
(Benner, 1984).

The Acculturation of
the Professional
In her 1974 book Reality Shock: Why Nurses Leave Nursing, Marlene
Kramer discussed the discrepancy between the education the student
received and actual nursing practice. Kramer described the inherent phases
of acculturation as being the honeymoon phase, the shock and rejection
phase, the recovery phase, and the resolution phase. Initially, the new
nurse is excited and enthusiastic about finishing his or her degree and
beginning in the profession (honeymoon). Following this phase, the nurse
becomes disillusioned (shock and rejection). With experience, the nurse
gains perspective and begins to recover (recovery). Finally, the new nurse
must decide how to move forward—whether to adapt to or leave the
current position or go back to school (resolution).
 Introduction xix

Note
Relationships appear to be significant to the ability to adapt—
particularly relationships with physicians and other staff. In
addition, relationships with other nurses seem integral to a
good experience as a new graduate (Kramer, 1974; Martin &
Wilson, 2011).

Hoffart, Waddell, and Young (2011) also write about reality

shock and how it continues to hamper transitions for new nurses. They
acknowledge Kramer’s assertion that it is vital for new graduate nurses
to move beyond feelings of shock and find ways of overcoming their
disillusionment and anger.

Nursing schools have found various ways to better prepare new

graduates for this difficult transition. Among these is clinical experience
that is precepted during the final year of school. In general, students who
have had preceptors seem to feel more comfortable with the expectations
of the nursing role (Wieland, Altmiller, Dorr, & Wolf, 2007). Other
programs that have been studied include externships, cooperative
education programs, and nurse residencies. (Of course, it is difficult to
determine how formal programs to aid new nurse transition affect new
nurses in the long term [Hoffart et al., 2011].)

The Responsibilities of
the Professional
In her 1984 book From Novice to Expert: Excellence and Power in
Clinical Nursing Practice, Patricia Benner wrote about the experience
of being a novice nurse and how nurses progress through several stages
to become expert nurses. The novice nurse struggles with the basics of
nursing practice. As the nurse gains experience and competence, he or she
gains perspective on what it means to be a nurse and how to perform well.

According to Martin and Wilson (2011), managers, preceptors, and

educators are responsible for nurturing new nurses as they move through
the phases of development. They advocate for instructing staff in what
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