Progress requires change, and this may require new external input. Newly graduated nurses are trained to challenge current practice in the healthcare system. However, a new study shows that this is challenging because the desire to be accepted as “part of the family” and the fear of appearing incompetent often make newly graduated nurses less willing to ask questions. The researchers think that nurses lack awareness that being critical of one’s own and colleagues’ practice is essential for developing as nurses and ensuring high standards in nursing.
When a daily work routine is under maximum pressure, adhering to the usual established practice is often the easiest way out. Lack of critical reflection can mean that nurses only minimally draw on knowledge from research, patients and other aspects of evidence-based practice. Studies have shown that, although new graduates are trained to work based on evidence-based practice, they have great difficulty in involving patients and research in their daily decisions. A new study focuses on why.
“Newly graduated nurses are often parachuted into a complex situation characterized by many new and unknown tasks. Nursing care requires that the nurses ask questions and enquire how they can provide optimal care. Our studies indicate that the new nurses do not ask the experienced nurses questions about patient care because they are concerned about being perceived as inadequate, insecure and not equipped for the job. Further, the experienced nurses often answer questions by saying ‘if it was me I would do it like this’. Integrating new knowledge to benefit patients primarily requires a work culture with room for questions and ongoing dialogue among the nurses about whether practice can be carried out differently and better,” explains Siri Lygum Voldbjerg, Postdoctoral Fellow, Clinical Nursing Research Unit, Aalborg University Hospital and Senior Lecturer, University College of Northern Denmark.
But we have always done it this way!
Healthcare systems worldwide increasingly require that clinical decision-making includes evidence-based practice that incorporates patients’ experiences and preferences and the highest-quality research. This approach began in medical practice in the early 1990s and influenced nursing a few years later with the expectation that new input from research would change practice. Evidence-based practice requires a questioning approach and critical thinking, which newly graduated nurses can provide through their curiosity and lack of experience.
“Newly graduated nurses are a valuable resource. They are specifically trained to both acquire new knowledge and put it into practice when they graduate. However, since studies have indicated that this has not been very successful, we decided to observe and interview 11 newly graduated nurses on their shifts to see how they are encouraged and hindered in incorporating new knowledge into practice and involving patients in decisions,” says Siri Lygum Voldbjerg.
The researchers observed the nurses on one to three 8-hour shifts. The resulting 174 hours of observation and the interviews showed how decisions were made and how the graduates’ socialization into a ward and a new working environment influenced their questioning and critical approach to practice and thus their decisions on patient care.
“The overall conclusion was that their pursuit of recognition from their new colleagues most often unintentionally suppressed their desire to explore and challenge current practice. Our observations and interviews show that they are concerned about standing out. New nurses will do anything to become part of the family and be like the others, so they are not excluded. They also fear that overly questioning behaviour will make them appear insecure or critical of the more experienced nurses,” explains Siri Lygum Voldbjerg.
The way the more experienced nurses responded to the new nurses questioning existing practice were not always conducive to change.
“Rather than leading to discussion and reflection, the enquiry was often rapidly deflected by a ‘this is how we do things’ answer. This left little space for questions and critical reflection,” says Siri Lygum Voldbjerg.
Communication is key
Instead of implementing new research knowledge, the new nurses often used the experienced nurses as the predominant knowledge source.
“In a busy work environment nurses often choose the existing practice and the source of knowledge that is most easily accessible. However, this is probably also related to how they are assessed and what documentation is required. Our study showed that the nurses primarily focus on the new knowledge aimed at the more task- and technically oriented part of nursing such as administering medication or changing dressings, whereas recommendations for the more intangible aspects related to developing therapeutic relationships are more quickly brushed aside,” explains Siri Lygum Voldbjerg, emphasizing that this type of practice can be extremely important to focus on and question, since inadequate communication and relationship-building between patients and nurses can lead to many unintended consequences.”
“Communication is key to nursing care. For example, a patient may previously have received a certain medication and knows that this causes a rash or more severe side-effects, but the patient may think that this is the only drug available and so does not ask about alternatives. Optimizing dialogue and close relationships is therefore essential.” says Siri Lygum Voldbjerg.
A natural part of nurses’ DNA
The study provides food for thought for the future education of nurses. Do the students learn appropriately, or is it futile to train nurses to have a questioning and critical approach? The researchers say that students must develop the self-confidence to challenge current practice. Nevertheless, another initiative is even more important.
“Developing a supportive culture is extremely important. Newly graduated nurses need to be considered a resource, and questioning current practice must be a standard part of being a nurse. Even busy nurses must take the time to reflect on how to optimize care for each patient. Otherwise, the development and thus the quality of nursing care will come to a halt. Developing clinical practice requires critical questions,” explains Siri Lygum Voldbjerg.
A major interinstitutional collaboration has been established in the North Denmark Region based on the Fundamentals of Care framework to create cultural change focusing on the complexity of nursing and the importance of involving patients and research evidence in decision-making. Hospitals within the North Denmark Region, municipalities, the University College of Northern Denmark and Aalborg University have entered into a strategic research collaboration focusing on establishing evidence-based practice with a critically reflective culture.
“Today, we often parachute newly graduated nurses into an untenable situation. We hope that creating a common conceptual framework for nursing across healthcare institutions will give both experienced and new nurses a collective starting-point for discussing and debating nursing. What are we talking about? What should we emphasize? Can we do this better or differently? The question should not be whether they dare to challenge existing practice but how to make this a natural part of a nurse’s DNA,” concludes Siri Lygum Voldbjerg.