Beyond Nurse Residency

Transition Theory with Dr. Judy Duchscher

• Nicole Weathers, MSN, RN, NPD-BC • Season 2 • Episode 1

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Navigating the transition from nursing student to practicing nurse involves overcoming significant challenges, specifically during initial employment periods marked by transition shock and crisis. Insights from Dr. Judy Duchscher emphasize the need for structured support, theoretical frameworks, and fostering mentorship relationships to effectively guide new graduates through these critical phases.

- Understanding the purpose and structure of nurse residency programs
- Differentiating between transition shock and transition crisis
- The importance of mentorship and support for new graduates
- Recognizing the emotional and psychosocial needs during different stages
- The value of peer mentorship and initiatives like Storm Chaser
- Addressing the need for theoretical frameworks in residency programs

GUEST: Dr. Judy Boychuk Duchscher's lifelong passion has been exploring the professional role transition of new graduate nurses. Her encounter with Dr. Marlene Kramer spurred her to make strides in this area. Over the past twenty-five (25) years, she has engaged in extensive research to shed light on the professional role transition of new graduate nurses, an aspect of nursing that can easily be overlooked.

Her nursing career commenced in 1979 after graduating with a diploma in nursing with an initial focus on growing her expertise in providing direct care in high-acuity care settings. Her credentials include a Post-Graduate Diploma in Intensive Care Nursing from the University of Manitoba, a Diploma in Cardiovascular Nursing from Stanford University, a Clinical Transplant Coordinator Diploma from Johns Hopkins, a Critical Care Registered Nurse (CCRN) certification through the American Association of Critical Care Nursing, a Post-RN Baccalaureate and Master's degree in nursing from the University of Saskatchewan and a PhD from the University of Alberta among many others.

She has earned recognition within the nursing community for her numerous contributions to the advancement of the profession particularly in supporting new nurses' professional role transition. Presently, she serves as an Adjunct Associate Professor at Thompson Rivers University School of Nursing, the Director of Nursing The FutureTM (NTF), and the Principal Investigator on a 4-year (2023-2027) Health Canada grant to evaluate the Canadian National Nurse Residency Program. Through these roles, Dr. Duchscher continues to display her unwavering commitment to supporting and educating new nurses and bridging the gap between undergraduate nursing education and professional practice.

https://nursingthefuture.ca/

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Nicole Weathers:

You're listening to the Beyond Nurse Residency podcast, an educational series where we interview experts on all topics related to the transition of new graduate nurses into practice and beyond. I'm your host, Nicole Weathers, Director of the Iowa Online Nurse Residency Program. Thanks for joining us, let's jump in.

Nicole Weathers:

Nurse residency programs have been around for over 20 years. Initially developed to address high turnover rates among new graduate nurses, many organizations have since adopted these programs to continue to work on improving retention. However, through conversations with nurse educators and nursing professional development practitioners over the years, I've realized that not everyone fully understands the theory behind these programs, why these programs are effective and the specific challenges that new graduate nurses face. Early in my career as a nursing professional development practitioner, I learned about the transition stages and shock models. This awareness made something click for me, helping me to make sense of my own experience as a new graduate nurse and helping me to become a better support for the new graduate nurses in my care.

Nicole Weathers:

In this episode, we are going to discuss the transition theory, what it is, where it came from, how it's evolved over the years and how it fits into today's nurse residency programs. My goal for this episode is for our listeners to walk away with a new understanding and actionable steps they can take to improve their work. So today, we have Dr. Judy Duchscher as our guest on the podcast. So hello, Judy, how are you today?

Dr. Duchscher:

Hi, Nicole, I'm just fine, and thank you so much for asking me to join your podcast.

Nicole Weathers:

Well, this is a very exciting podcast. This will be the one that kicks off our 2025 and season two of the Beyond Nurse Residency podcast, and as I was thinking about guests to invite on, I thought who better than one of the first names that I've ever heard when it came to nurse residency program and transition to practice support? And that, of course, is you. So this is very exciting. I know I've read a lot of your articles. I've used your theory many times to support a lot of the work that we do with our online nurse residency program, and so it's just an honor and a privilege to be able to sit down with you today and talk with you about all of this great work that you have dedicated your career to and how much this has impacted our nursing profession.

Dr. Duchscher:

Well, that's humbling, a humbling introduction. I hope I can live up to it.

Nicole Weathers:

Oh, I'm sure you can. I'm sure you can, so why don't you take a minute and just tell our guests a little bit about yourself?

Dr. Duchscher:

Oh well, thanks so much, Nicole. I've been in the profession for a very long time at this point, 44 years and seen a lot right, seen the profession through a lot of phases and stages. So it's fascinating, to be honest with you, to see what's happening now and compare it to different parts of my career. Right, opportunities abound in nursing and that's the wonderful thing about it, if you have the courage to take advantage of those opportunities and you know. Speaking of transition, I was introduced to the concept of reality shock when I started looking into the concept of transitioning into professional practice for newly graduated nurses. Of course, for me the first thing that came to mind like for you it was me and for me it was Marlene Kramer, and Marlene Kramer was from UCSF, I believe, and Marlene wrote the book, "Reality Shock Why Nurses Leave Nursing" and I was just captivated by that. But it came a little bit later in the story about my transition theory. And, by the way, all of this is available to people on the Nursing the Future website under the transition theory area of the website, and I've just really buffed it up with a lot all, in fact, of the other transition theorists that people might be interested in using for the purposes of guiding newly graduated nurses.

Dr. Duchscher:

I think it was oh goodness, it was a long time ago, let's put it that way and I was in my master's degree and during one of our classes they said we had to review the literature and find the hole in the literature, and that's what we should study. Well, at that time that I was doing my master's degree, many years ago, critical thinking was just coming into vogue and I was fascinated by the cognitive elements of our practice. And I read this one article that measured the critical thinking, using the California tool, of students from the time they started their program until the time they finished their program and then, at six months after they graduated and appropriately so, unexpectedly, their critical thinking rose over the four years of their undergraduate program. And then there was this fascinating drop in their critical thinking process at six months when they measured it, and I was like that's a hole, because they couldn't explain it. They could just tell us that this is what they found and I thought, oh, I have to explore that.

Dr. Duchscher:

So my first study and I've done 14 studies on the concept of transition shock to continue to, you know, renew my model or ensure that it's appropriate for the time, and that's a good grounded theory, I think, is that it transcends a lot of that, but as a theorist, you know you always want to make sure that it's up to date, if you will. But anyways, I was curious about what happened in their thinking process. So I went in to study the critical thinking of a newly graduated nurse and I started at the very beginning of their transition and I went to six months just so I could see what was happening. And that was the birth of my last 25, 26 years of researching this topic, because I was absolutely drawn to their struggle, because it was so powerful and so emotional and so absolutely at the core of who they were. There was so much going on, and so that's when I started to explore this idea of what's going on and I stumbled over Marlene's work.

Dr. Duchscher:

Now, Marlene at the time this was the late 1960s when she did this research on reality shock she only did one study and I thought that was fascinating because people had been using that theory, you know, forever after that and it was based only on one study, and when I actually went in to look at it, it was such a much more complex and convoluted experience it wasn't as linear as I felt it was being presented and Marlene agreed with me. You know, years later, when I started to develop my theory and we kind of moved, if you will, from reality shock into this concept that I've birthed called transition shock and then the stages of transition. So it was wonderful to work with Marlene for about 10 years and she passed the gauntlet to me to explore this deeper and that's what I've been doing. So that's kind of how the transition theory was born.

Nicole Weathers:

I think it's so interesting that you didn't get into it thinking you were going to study transition, the transition experience. Right, you were looking at critical thinking, and it's so interesting, though, even that study that you shared where critical thinking rose until it didn't, and then you saw that mark to decrease and that that really coincides with the idea of transition shock, or reality shock, and that that is having a direct impact, obviously, to critical thinking.

Dr. Duchscher:

Well, you know, the interesting thing about it is that my research demonstrates that there are two real crisis periods for the newly graduated nurse. The first one is transition shock, and that happens within the first couple of weeks of being autonomous or independent or hopefully interdependent in their practice, where they really feel the weight of the responsibility and all of a sudden nobody's following them around picking up the pieces that they dropped, which is what happens a lot of times with mentors and preceptors. They're nurses, so they tend to be pretty nurturing kind of people and they'll watch the new graduates struggle and, like anyone that you watch struggle, you want to help them, and so they think they're helping them by, you know, picking up what they've left behind or not finished or whatever. But they don't tell them right because they don't want them to feel bad, so they continue to mop up after their mess. And then all of a sudden, when the new grad is independent and on their own, they're like, okay, so what just happened here? Because I thought I was coping quite well and it's because all of a sudden they've got all these other pieces. So I talk to mentors and preceptors about that and let them know that at a particular point you need to pull completely back. Let the graduate know that you're pulling back. If they want you to help them, they need to ask you to help them, but they must understand the comprehensiveness of their role and they won't if you keep doing that. But yeah, that transition shock is like holy crow. I didn't know I had to do all of these different things that people were doing for me before or that my instructors didn't allow me to do, or school as a student you're not allowed to do a lot of the things that you'll be doing as a registered nurse. So there's that. Then they kind of get accustomed to everything and at about the six to eight month period is another and this is demonstrated visually in my model.

Dr. Duchscher:

There's another period that I have identified as transition crisis, and it's almost like they're comfortable with what they have to do as a nurse and all of a sudden the realities of the workplace, the realities of the healthcare system, both, which are fractured and imperfect, like everything, are revealed to them and they stop and they're like, oh, my goodness, what are we doing? That sort of thing? So when people say, well, how would you identify the differences between shock and crisis? And I say shock is like oh my, I don't know if I can do this. And that's the initial whoop. The crisis is I don't know if I want to do this. That's the initial whoop. The crisis is I don't know if I want to do this. And that's a real difference.

Dr. Duchscher:

And I always say to people working with grads you need to be really aware of where they're at at around six to seven months, because they are making some pretty big decisions at that point that they may not tell you about and those decisions, interestingly enough, are often grounded in that initial stage, which is the first four months of practice. What happened? Were they supported? Did they have a major challenge to their confidence? Did they make a huge error? Those kinds of things can completely crystallize the way a new graduate feels about themselves and will feed into that transition crisis experience when they can stop and take a breath and look around.

Nicole Weathers:

I love that you describe it as a first is can I do it? And then do I want to do it? Because you're right, those are two very different things, and maybe we've proved to ourselves that we can do it right we can do this type of work, but maybe am I in an organization where I feel supported enough to want to show up and do the work.

Dr. Duchscher:

Yeah, I think of them as the first one is a reaction or response, but usually a reaction, and the second one's a decision.

Nicole Weathers:

And I think such an important reason to why this nurse residency transition to practice program support, whatever it is called or looks like in the organization needs to be in place at that point of that decision. I think we would be doing a disservice if we maybe didn't have that in place or it ended prior to that sort of decision point.

Dr. Duchscher:

Oh, okay, you've hit on something there, Nicole, because a lot of these programs say we're going to support you for three months, we're going to support you for, you know, six months, oftentimes not six months. Oftentimes you're lucky if you get 12 weeks of support, but generally those residency programs are set for about a year, but it's what they do throughout that year. That's really important and I think this is where my theory can help people and that's why it worries me when I see residency programs and we have a number of them in Canada that aren't necessarily based on a theoretical framework, they're just skill competency. And that's not the only thing going on for the newly graduated nurses. You can see if you've read the work that I've offered. It's a complete process. It's emotional, it's psychosocial, it's spiritual, it's physical, it's intellectual, it's relational, it's cultural.

Dr. Duchscher:

I think I might've said that it deserves two mentions, because the culture in the workplace determines a lot of our capacity and our ability to succeed as professionals. So, yeah, I think that the nurse residency programs are one, and the US is way ahead of us in this idea. Canada is just piloting at the moment, over a four year period, a national nurse residency program and I'm heading up the research for that national residency program and it's very interesting. The support that they get is crucial. The mentorship is crucial. So, yeah, I'm just so excited when people approach me that they've got a residency program and they want to frame it with some kind of theoretical underpinning.

Nicole Weathers:

Excellent. Well, maybe now it's a good, you've kind of gotten into this a little bit and so this might be rewinding just a tad. But we know where the theory came from, how this sort of came to be. So maybe now would be a good time for you to explain sort of the basic tenets of what is your theory.

Dr. Duchscher:

Thanks, Nicole. I think if I were to summarize it, I would suggest that it offers a predictable set of stages and phases within which you build initiatives to target those particular challenges in those particular stages and phases, and again in those particular stages and phases. And again this is outlined in a lot of detail both on my website and in my book. But stage one is the doing stage, and I identified it as a doing stage because that's what they're focused on. They're focused on doing what they need to do, first of all without hurting anyone and, second of all, without their colleagues noticing that they don't know how to do nursing. And that's why nursing at that point in their careers is relatively skill and competency focused, because that's what people can see. They can't see what's going on in the mind and the heart and the soul of this graduate. They can just see what's coming out in physical form. So they're very aware that they're being watched. They're very aware that they're being judged, and so this is an interesting stage because the graduate is trying to fit in. That is their number one objective in that initial stage is to belong, to fit in. So if that means adopting, accommodating, assimilating to some practices that they may not completely understand or that look different than they thought those things were going to look, based on their education. That can be a pretty precarious time for the graduates Because even though they might think in their heads okay, I'm just going to do it like this, because if I don't, I get this really negative response, so I'm going to do it so that I can fit in they might even be thinking and later, when I'm more confident, I'll reevaluate this. Very often they don't reevaluate that. They become so used to doing it. However, it's done in their workplace, which may not be optimal, but they're so used to doing it that way that they never actually revisit and pull their standards back up to where they were when they graduated. So that can be a precarious phase.

Dr. Duchscher:

It is really fraught with stress. It's stress about everything, right, I mean they. They're stressed because they want to be a good nurse. Who doesn't want to be a good nurse? They're stressed because they're often engaging in personal behaviors and and events in their life that they highly anticipated or didn't for instance, a divorce or a financial challenge that they come upon that they've never had to deal with before moving out and taking care of themselves. Oftentimes these are all causing them stress. So I always tell people that there are four foundational elements that thread their way through all the stages and phases, and they are stability, familiarity, consistency and predictability. So the graduate needs those four foundational elements paid attention to, and this is both personally and professionally. So I say to people okay, if you're thinking of moving out of the home that you're in and if you're thinking of getting married, if you're thinking of getting divorced, whatever you are already destabilizing your environment and so pick a workplace that is very stable, and that means stable staff, stable patients, that sort of thing. So if you're going to be unstable in one area of your life, you need to ensure you'll be stable in the other. So this is why thinking about where the grad is going to go work is really important. So that's sort of that first stage.

Dr. Duchscher:

The second stage is a stage of real exhaustion because, as you can imagine, everything has hit that graduate in that initial four months, which is the first stage. They're focused on belonging, they're highly stressed about everything that they're doing. They can't make really good decisions in that first four months because they haven't learned how to differentiate information and so they will take a relatively linear approach. Usually they'll go A to D. A, B, C, D, and they'll see nurses around them go from A to D and they're fascinated by that. They're not comfortable with it, but they're fascinated by it, and so the more that you can save them. You might be used to doing this and going here to here, to here to here. Now I'm jumping to here because of the following reasons Boom boom, boom, boom. Then the graduate understands the thinking process that went in to the differentiation of the process. If not, they're going to skip B and C, with everybody thinking that everybody goes from A to D on this unit, so I better go A to D, so those kinds of things. That thinking process is really crystallizing in that initial stage.

Dr. Duchscher:

So in the second stage, which is where the transition crisis process is, I think if they've had a relatively decent first stage, they have started to settle into what it means to be a registered nurse in this context, on this unit, in this institution, in this health region, and they start to relax. They don't dream about work every night, they're not nearly as stressed about their day-to-day functioning, they start to pick up old friendships and what they will often do is pull away, in fact, from the workplace, so not wanting to work as much over time, sensing the tremendous level of exhaustion that they're feeling, and just wanting to kind of chill and say, okay, what just went on here, because I'm exhausted and there's so much that I've seen that I haven't processed, so I need to process that. So they pull back a little bit. When they do, they tend to reflect more on the larger system issues. So the fact that we don't ever have any staff, the fact that the manager won't allow us to apply for overtime, the fact that our resources, our actual stock and supplies are never there when we need them, those things really start to bother the graduate.

Dr. Duchscher:

And this is where they may make decisions about the workplace that they're in, thinking that if I just change my workplace, those things will solve themselves, which of course oftentimes they don't. They go into a new workplace if they choose to. At that point and the same thing starts to happen. They go back to stage one, they come to stage two and they see the same sorts of realities hitting them. Back to stage one, they come to stage two and they see the same sorts of realities hitting them.

Dr. Duchscher:

So having people at that point, at about that, four to six to seven month period, checking in with that graduate and saying so, what do you think about our healthcare system? How are you managing to find balance with your home life and your work life? What are you doing to do that? How do you deal with your stress? All of those things that they can now pay attention to? And so it is encouraging that they do step back, because it tells me that they're starting to think more about what's going on and what's going on. And then, if they do a good job in that second stage of regrouping and putting all the boxes in their place, and they're like okay, and they have people around them who say I know, when I first kind of saw the health system the way it was, I found the following things frustrating one, two, three, and this is how I chose to deal with those in a healthy way.

Dr. Duchscher:

Well, that's great, because if the graduate can come to those sorts of conclusions, then as they reach the third stage, they've got a pretty healthy sense of what they're doing, what they want, how to maintain their values and they start to think about the future. So offering a graduate an opportunity for something futuristic in the first stage is time wasted. You know, following them too closely in that second stage, when they're trying to test out their own thinking and their own decision making, is also not helpful. So if you don't understand the primary challenges that are occurring for them in each of the stages, some of the assistance is offered at inappropriate times, which is a waste really. So those are kind of three stages in a nutshell, and I'll let you ask me questions that can help me elaborate on things that weren't clear, Nicole.

Nicole Weathers:

No, I think that you did a fantastic job explaining that, and that is a lot of times when we're talking about. So we help a lot of organizations bring nurse residency support into their organization, and those are a lot of things that we talk about, obviously based off of the things that I've read by you and others. But the fact that you know, in those first months they're just so focused on how do I survive the shift right, how do I get through the day to day? That's really where we need to be focused on supporting the most day to day. That that's really where we need to be focused on supporting the most. And then stage two, where you, you begin to have some of those questioning sort of experiences where not only is this something that I can I do, but also do I want to continue to do that. And then so talk a little bit more about stage three. How do you know when somebody sort of got to that point?

Dr. Duchscher:

Yeah, that's a good question. I think they're. They're far more settled. You know they they come to work not an hour before, but they come to work at a normal time. They participate in social activities on the unit. When they're on their break, you know, they'll talk to people and and they're not just completely obsessing about getting back to their patients because they forgot to do that or they have to do that they can find a more relaxed pace for themselves.

Dr. Duchscher:

You might find in the second stage that they're calling in sick or they're not accepting overtime or things like that because they're just too tired. So they might start doing that again. And I think you know when they start to ask questions about how they might advance themselves on the unit or in nursing, they've reached that third stage and they're starting to think about the future. Anytime they're still reflecting. You know the first stage is like in the moment they're not reflecting really on anything other than in their dreams. And then the second stage, and maybe toward the second stage, they start to do a lot of backward reflection and then in the third stage, you start to see them thinking about their future, and so I would suggest that those are some of the things you'll find.

Nicole Weathers:

Excellent. So you started your research on this topic over 20 years ago and now that we know where it started, how it came to be, I'm just curious has this research evolved and grown over the years? Have you discovered new trends or anything in more recent years that maybe you didn't recognize when you first started looking at this topic?

Dr. Duchscher:

Well, you know, I didn't write the theory until after about five studies, so I took my time before I actually launched it, and the reason is I wanted to feel like I had teased my way through some of those things that people are like well, what if they're in a different kind of a unit, or what if they're older and more mature?

Dr. Duchscher:

So I wanted to work my way through those to a good grounded theory place, which a grounded theory if it's a good grounded theory should be able to transcend a lot of those more superficial contextual changes.

Dr. Duchscher:

And I think when it initially was launched, I was really comfortable and confident with it. Since then, I mean, I really I I've not changed anything in the theory, but I do talk to people about how context like COVID, for instance, how it might alter the way that people progress through the stages, how the challenges of the first stage in particular were highly impacted by COVID and so it was far more intense. And now I think what we're finding is that the second stage is really challenging for the newly graduated nurses, where they're making decisions to leave really quite early, and I think it's simply because they are seeing the fractures in the healthcare system that we had managed to patch with Gorilla Glue that we had managed to patch with Gorilla Glue, and then in the COVID era, I think, some of that glue came undone and started to reveal pretty significant fracture lines that we were able to hide before, and so I think that's why that second stage for graduates in the last couple of years has been profoundly impactful.

Nicole Weathers:

And you know we talk to people a lot, and some of our more experienced co-workers will talk about you know how well we didn't have this sort of thing when I was coming up through the ranks, right Like I didn't have this as a new grad 40 years ago. Why do they need it now? And so how do you, I guess? How do you respond to that type of statement?

Dr. Duchscher:

Well, since I started 44 years ago, I know exactly what they're talking about. I mean I was working in coronary care and I was looking at monitors and studying all night. I mean you know like we were able to manage the clinical load that we had. I know that we had a larger number of patients oftentimes, but some of them were out on pass. A lot of them were just really stable Patients these days in hospitals are simply unstable situations and the acuity is much higher than it used to be.

Dr. Duchscher:

The staffing shortages I mean we didn't staff all that well, but it wasn't because we were necessarily short, they just didn't staff well back then. Now they are not capable of staffing. So the people that do come to work are often exhausted because this is their third or fourth shift and two of those are overtime, et cetera, et cetera. So I think the environment has definitely changed. The other thing that's changed is the graduate themselves. And be careful, what you wish for right. We've always said you know, I wish we could just say no, I'm not going to take it. And well, that's exactly what they're saying and they might say it by speaking, you know, up at their workplace and people who've been there and lived through all that challenge are like excuse me, who do you think you are? Coming in here with one year of experience and telling us that this is not adequate, that you need more of this and you need more of that? I never had that? Well, that's not an answer, right? That is saying that you shouldn't get support because I didn't have support is certainly not a healthy response. So a lot of this is grounded in the idea that if I didn't get something, no one else should, and that's a human response. When there's residual frustration, when you don't feel valued at work, that's your go-to place.

Dr. Duchscher:

These graduates are not interested in that. They also aren't going into nursing for the same reasons. They're going into it because it's a pretty decent moneymaker. They can choose their shifts, which is why a lot of them like to be casual, and a lot of institutions now aren't even offering casual, which is a flip.

Dr. Duchscher:

They realize that they're not getting the institutions out of the graduates and the nurses what they need by allowing them to work casual. It's just too easy for them to say, no, I don't think I'll come in, I don't think I'll cover that shift, et cetera. So the graduates are being put in these full-time positions into these environments that are really stressful and the expectations are incredibly high because the patients are sicker and the institutions have less resources and these grads are like. But I don't want to commit my life to this. This is just something that I do so that I can live my life and it's very different from the way I, as a boomer, went into my profession. I went into it to make a difference in the world, and it's not that the nurses now don't want to make a difference, but they're not willing to sacrifice their personal lives to make that difference.

Nicole Weathers:

Okay, so let's talk now about the role of nurse residency. So, of course, popular strategy to support this transition to practice experience. As we work with organizations across the country I see how much they vary, though, from one organization to the next, and we kind of touched on this already but, based on sort of your research, how do you see nurse residency programs as the tool for offering this needed support, and what key components maybe do you feel every residency program should include to effectively meet the needs of those new graduates as they go through these different stages and experience both transition, shock and crisis?

Dr. Duchscher:

Well, you know, variability is okay If it attends to local or regional approaches or policies that are institutional, that aren't in another institution. So some variability is expected. It's what you choose to be consistent on that matters, and I do think this is where your theoretical foundation comes into play, and you need a theoretical foundation for what you're doing, what you're expecting and how you're approaching those new nurses. Whatever theory you decide on, use something. I do believe that people think that it's all about skills and they don't understand the interrelationality between your practical or pragmatic development and how it's related to your cultural, psychosocial, spiritual development and how the two of those are intersecting with your cognitive capacity. So I believe that people need to think more broadly. I did so in my theory, which is why it offers a much broader sense of what that graduate experience is than perhaps just the reality shock idea. And again, this focus on competencies, I get it, it's important, but if you don't understand what might be impacting their cognitive capacity or their progression through the transition experience, then you won't understand how to develop their competency. And so this is where I think if you know where they're at in their minds and their bodies in that first stage, you will appropriately and gradually and intentionally direct them in their both social development as well as their physical development. How to cope with 12-hour shifts, how to cope with moving from nights to days these are all things that are really important and you could think of those as skills as well, I would suggest, and if people are following the stages and they understand them, they would do this as well. But that's the starting off with a narrow skill focus and this almost sounds like it's contradicting what I just said, but it's not because their focus is on their skills in that first stage. In order for them to feel confident with their peers, they need to be able to demonstrate their competency.

Dr. Duchscher:

So I always say to graduates when you enter that workplace, you tell them that you want to be able to do the five things that are done consistently on this unit really well before you become independent. So I say, why don't you get to huddle and tell everybody? Today I am going to be monitoring everyone's heparin drips, so I'm going to look at the APTTs, I'm going to talk to you about them, I'm going to alter the dosages, I'm going to order the blood work. I'm going to do all of that because that is a skill that has to be done on this unit almost every day, okay, and then you extend that to five skills. If within the first couple of weeks they have been able to do that. And, by the way, when you stand and huddle and say that everybody, I'm going to do all your admissions and discharges this week, they're going to be really happy with you. So it's also a way to engage that graduate in everybody on the unit. They get to know people. Again, that's an important piece, that sociocultural piece. So if you focus on those competencies until they're comfortable with a certain base set of skills, then they're not constantly worried about those as they move into their independent practice. So that's just an example of how, if you understand the stages, you would work with them in a particular fashion that you might not if you didn't understand what was going on.

Dr. Duchscher:

So I think the key overall is staged, supported feedback and intentional increases in workload and skill expectation. But they do need to leave their work, at least initially, satisfied and successful and so putting them in situations that don't satisfy them and allow them opportunities to make error without that support of OK. Well, you know, it's understandable that you made that medication error because, as we talked about. You got distracted by that other patient. So what have you learned by that? That sort of thing, this really intentional mentoring, debriefing, deconstructing and reconstructing, is critical in that initial up to six months. Then you've got a solid, healthy, probably confident practitioner that you can then start to increase their workload. You can start to put them in situations that are less predictable, less consistent, less stable. So that's what I would say are key elements of a residency program the one-on-one support, the staged intentionality of that support. So your mentors, your preceptors, they need to understand the transition stages, they need to understand shock, they need to understand crisis. That's the way that they will be able to predict what that graduate might be going through.

Dr. Duchscher:

For instance, if you're in stage one, you know the graduates concealing from you. So how do you get them to share things with you that they would normally conceal? Well, they have to be in a trusting relationship with you. They have to feel like you are all about their success, that when they come to you with a question that you might think, okay, this grad should probably know that you don't say that, you say, okay, let's go over that.

Dr. Duchscher:

So on the third time they ask you the same question. You can sit down with them because they trust you now and you can say you know this is sounding like a similar question to what you've asked a couple of times before. So I feel like somehow we haven't helped you with that, not somehow you're just failing. No, if, if you're still asking those questions, it's something we haven't done, it's something we haven't recognized. It's like the patient who's on the bell all the time. The nurses should look at themselves and say what is it that we're not meeting in terms of a need in this patient? Same thing with the graduate. I would suggest those are our foundational elements of a residency program.

Nicole Weathers:

I love that and I mean I think that's something too that we have thought a lot about with our curriculum.

Nicole Weathers:

That sort of goes you know they're out there, they're working their shifts, they're working with the preceptor, but then, as we are introducing some of the you know more classroom style education to them, really trying to match that with where they're at in their transition, because if we come at them with evidence-based practice in month one, it's a waste of time, right, because all they want to know is how do I get through my shift, how do I take care of my patients and not hurt anybody?

Nicole Weathers:

I mean, that is what they're focused on. Therefore, that's what we need to be focused on with them. If we want to get into some of those other concepts through the program great and, I think, important it just needs to come, like you said, kind of beyond that six month point maybe, where you know they're feeling really comfortable and competent in that day to day sort of skill and routine. Say that because that is really kind of the approach that we've taken with our curriculum and I think new grads appreciate that right. It's not that they're not interested in some of those concepts, it's just that's not where they're at at that point in their transition experience.

Dr. Duchscher:

Yeah, absolutely, and I've got a couple of models in my book that I created so that people could see within the stage what is the best support process.

Dr. Duchscher:

So initially it's, a lot of it is perceptorial, right, you know, it's about one to one to one alongside skill, skill, performance, and that's normal, that's okay, you can just focus on that.

Dr. Duchscher:

But as you move into that fourth month, then you want to start challenging and being aware of what their thinking process is. So they you don't want to just tell them what to do, you want to start asking them questions about what they're going to do and what would you do if this happens and what would you do if that happens. So you start to get a little bit more cognitive with them and then, as you enter that second stage, a lot of it is the cognitive building. There's a huge uptick of intellectual capacity in that second stage because they're much more comfortable with their practice and then they can start thinking about well, why am I doing it this way as opposed to just do it that way? Get it done and do it, you know, successfully, in a healthy way, and then in the third stage they start to think about okay, now what? So you can see them go through those stages, and the way that you support their practice needs to depend on where they're at.

Nicole Weathers:

so you know, as I, as I told you, I think probably before we started recording um, I was thinking about who would be great to invite on um the podcast for 2025. And your name, of course, came to mind, and so I started Googling you and I discovered this website Nursing the Future. So can you share more about that organization, what is it, the inspiration behind it and what you offer?

Dr. Duchscher:

Well, I'll start with the inspiration behind it, because it was really quite remarkable. I am a very pragmatic individual myself. I was always that way. As an educator, I wanted to be practicing nursing alongside my teaching career and I did so for a long time until my transition theory work started to consume a lot of my time and energy and couldn't do that anymore, because I think it's important that those who are teaching our newly graduated nurses really understand the contemporary context of practice. So that's just a side note. But while I was doing my PhD, my father died and in my PhD I was doing the second study on transition to practice and started to really tease out some of those finer elements and I recognized that we really need to support our newly graduated nurses coming into practice. So I've got that lens on and I'm taking it pretty deep in my doctoral program.

Dr. Duchscher:

And my father falls ill and becomes a victim of the healthcare system. So he ended up getting very ill because of decisions that were being made by his physician and the lack of communication and synergy between the nurses, the physicians and all of the allied healthcare professionals. My father just basically fell through the holes in that system and he died because of that. So he died of malpractice in the end, and he had become pretty much every patient I had ever cared for as a critical care nurse. He was septic, he had just everything, and I watched him decline based on decisions that were being made clinically. I saw newly graduated nurses running around the unit doing things that they shouldn't have had to do, and in the meantime my father's potassium is 5.6 and they have not taken the K out of his IV. And I'm thinking, you know, you're not even able to spend time thinking about what's going on. So I decided after he died well, actually I was on his deathbed, having this terrible reaction to what had happened. I felt so betrayed by my profession. I felt betrayed by the healthcare system. I was very angry and I was steeped in my research which is a fascinating intersection and I remember standing over my father's bed in his comatose state and saying I would never go back into a hospital again. That was my anger speaking.

Dr. Duchscher:

Not long after that, I had an epiphany that the only way to change what was going on was to be in that system, and so my decision about that was to pull together a group of ex-students who had now graduated and who kept contacting me and saying, judy, I'm struggling with this, I'm struggling with that. So I brought them together and that was my initial Nursing the Future leadership team. And then I really realized how effective it was and I dug deep into this idea of developing young leaders who understood the concept of transition and who would then be able to support their peers in practice was because of my father offering me an opportunity to make a change in the world that might help patients in the future. So that's how Nursing the Future started. And when I started the initial iteration of Nursing the Future way back in I think it was 2001, I developed teams of new graduates and students across the country. Every province started to come on board and I would have oh, three, four, five in each province and I would bring them all together nationally every year and we would talk about leadership and we would talk about transition and we would talk about how to respond to grads and managers and educators who are working with graduates, et cetera. And it turned into conferences every year and workshops and it really started to evolve.

Dr. Duchscher:

But the funding was a problem. I ended up getting a lot of funding, I think upwards of a million in total over about 12-14 years in Canada. And then the money just sort of ran out. And it ran at a time when, when I was having an intersection of my own life that I needed to kind of regroup and think about how I was going to move forward. And when I finally did come back into my research after about three years of working as a manager to just take a break from the research and working directly with new graduates and seasoned nurses, that was an amazing experience. I came back into academia and started my research up again. And then COVID hit and people were very interested in supporting newly graduated nurses in this really crazy environment. So we got funding from our Canadian Nurses Association and Canadian Nurses Foundation and since then I've been supported by them to launch NTF 2.0, which is what I call it because it's a different model. It's primarily an asynchronous model.

Dr. Duchscher:

So what we do is we have all kinds of various strategies. So we've got the masterclass series. I just finished that with Jean Watson and we talk about how do new graduates stay those caring, compassionate individuals in the fray right, and we did like eight different interviews and ended up with five videocasts and they're available on the website. I'm currently for the masterclass series, doing a series on the state of nursing in Canada, and I'm almost finished that and a few of those are up. So there's the emerging career series where we interview, you know, mid career to late career nurses and say, how did you get there from being a new graduate? So that new graduates can see there's a path that you take to become a neonatal nurse, an intensive care nurse, a foot care nurse, whatever.

Dr. Duchscher:

They've tried to address the new graduate, their development, their engagement, their practicality and how to deal with the challenges and practice that they have.

Dr. Duchscher:

We've tried to address those issues from a variety of different lenses. We have one synchronous platform called NTF Live. Once a month I bring the speaker in and they're usually pretty prominent speakers that talk about something related to nursing in Canada or nursing in general and how new graduates can cope with those issues. So there's one recently called 'When Things Go South', dealing with crisis and chaos as a newly graduated nurse, and so I have critical care nurses and a new grad just came into critical care, a critical educator, and we talked about you know what happens when things go south. How do you cope with that? What are practical skills you can use as a new nurse, to stabilize that situation for yourself and your patient in the moment. So there's so many different platforms that we offer to address the different challenges that new graduates are going to have and also, nicole, the challenges that managers and educators are going to have working and preceptors working with new graduates so there's lots of content for them as well.

Nicole Weathers:

That sounds very robust in terms of all the different topics and tools and strategies that you are offering through the website, and to hear about your inspiration behind where this came from is inspirational all on its own. And to hear, too, the fact that you were doing this you took a little bit of a break, you did something else, you came back and now you're at this 2.0 version is a great story for all of us as we think of our own career development, you know wherever we might be. So, as you consider the future of transition to practice now, recent trends both locally, globally, within the nursing workforce, how do you see nurse residency programs or transition to practice programs evolving? Do you see any changes or innovations in the future to better support nurses in the years to come?

Dr. Duchscher:

I actually feel like if people could just get to the point where they have nurse residency programs, we would be ahead of the game. There are so many places that still don't have residency programs. I would love to think you are doing such a good job of this in the US. You have standards for nurse residency programs now through the ANCC, and I mean we don't have that yet in Canada. So I think that if you can continue to develop programs that are standardized and accredited which is where the ANCC has gone. I think good on you. Keep doing that.

Dr. Duchscher:

The only thing that I have noticed is that a lot of those programs still are not grounded in transition theory and, again, they're very competency-based. And I do think that we need to think larger when it comes to these new graduates, because it's a far more comprehensive experience than just I don't have the skills to do my nursing job minute by minute. I don't have the skills to do my nursing job minute by minute. It's bigger than that and I think we need to start thinking about how successfully are we engaging these new graduates in that third stage, in leadership activities that allow them to then say you know what? I want to do something about the transition experience of new nurses. I would like to become a preceptor or a mentor or take charge or whatever. I do think that peer mentoring is not where it ought to be and that was something I really learned in NTF 1.0, is that these individuals understand, like no one else can, what that experience is like.

Dr. Duchscher:

And I have an initiative. It's called the Storm Chaser, and these individuals are in my concept of the Storm Chaser. These are individuals between over one year to three years. These are nurses that have just gone through the transition, and the intent of the Storm Chaser initiative is to certify them in transition theory, chaos management and crisis intervention, and by doing so they would serve as the storm chaser.

Dr. Duchscher:

So if anybody says you know, I think Janice is struggling, I've just noticed a couple things. She's a new grad, whatever, Then you tell the educator, the educator contacts the storm chaser that is on your unit, or the storm chasers might cover three different units, but they are intended to be contacted early when there's a crisis brewing for this new graduate. They're just not coping and they would come in and intervene. They would talk to the graduate, they understand what stage they're in, they are good at crisis intervention and they understand how to help that graduate navigate the chaos of the workplace and you solve your issue. So, but that's that's peer mentoring really, and I do feel like that's something that I did a lot of in NTF 1.0 with all the teams, the peer mentoring teams across the country, without question, without question. That moved the needle more than anything else during those early years of nursing the future.

Nicole Weathers:

I think that idea of peer mentoring when we are talking with leaders about transition of new grads and the fact that they're like we don't have any experienced preceptors to precept these new nurses, it's new people precepting new people or mentoring new people Our response sometimes is maybe that's not a bad thing, right, because, yes, it's not a great thing because maybe they are burnt out and they've got a lot going on.

Nicole Weathers:

But just what you said is that these people are closer to that experience and they remember what it's like. If you've been a nurse for 20 years or 30 years or 40 years, it's hard to be back in those shoes of a new grad and be able to help with that. So I love this idea of including those one to three year nurses in something like this. It gives them that opportunity for that ongoing professional development. But also they are probably closest to what that experience is really like and remember how it was, how they got through that right, and I think they experienced it in a very kind of the same timeframe almost as what these nurses are experiencing it. So, even though I did experience that 20 years ago, practice today is much different than it was 20 years ago and so I just I really like that idea and I love that you call it the storm chaser. I think that's a really clever title for that concept.

Dr. Duchscher:

I did it because I wanted people to recognize that there are often storms brewing with newly graduated nurses. It's interesting with my research, nicole probably the most common image that was shared by new graduates over all of the years was this idea of being in the middle of a body of water, an ocean, whatever, and there's just a storm brewing all around them and the waves are high and they don't see the island they left and they don't see the island they're going to. They're just in this massive, frightening place and that's why I called it the storm chaser. Now I want to be really clear, because I think people just think you know, oh, the graduates are close to their experience and so they'll just naturally understand it. That's not always the case.

Dr. Duchscher:

So peer mentoring is not the blind leading the blind. It's important to make sure that that's not how it's presented. But rather, now that you're out a year, I want to go back and talk to you about all of those stages, because if I said to you now what was happening in the first couple of months of your well, I mean it was difficult, but you know, I got through it, and this is the way that graduates often think. They don't see the moment, after they're out a year or two, they've forgotten the incredible fear, the anxiety, the sleeplessness, all of that. They've forgotten all of that, as we often do when we've gone through a very difficult situation. So you need to take them back and say, okay, now we're going to look at this theoretically, so we're going to arm you with a reminder of what those stages were like for you, and then we're going to talk about okay, if a graduate is in stage one, these are the challenges that they're going to have. So then it's no longer the blind leading the blind, it's the knower leading the doer.

Nicole Weathers:

Awesome the knower leading the doer. I really think that is important and I'm glad that you brought that up, because I do hear that concept of the blind leading the blind all the time. When we start talking about newer nurses, precepting and mentoring newer nurses, and the importance of educating those individuals for those roles, I mean it's hugely important, right? We can't just because you know how to do a job or you've been through an experience doesn't mean that you can support and teach other people through that. So thank you for adding some clarity around that, because I think that's very important for our listeners to hear as well.

Nicole Weathers:

Well, we have talked about so many great things today. I have had such a fun time hearing from you, specifically about your theory, where the theory came from, having you explain it, because even though I've read many of your articles for me, I'm more of an auditory person. So having you explain that to me, I think I picked up new things, even though I'm not hearing it for the first time. So I'm sure our listeners will most definitely get so much out of everything that you have shared today. But before we go, I have one more question and I always like to ask this of all of our guests, but when it comes to transition to practice and our topic today and there's two ways you can approach this. So what's one thing you often see organizations maybe doing wrong or wasting resources on that really isn't making a difference, and what would you maybe tell them to do instead? Or, on the flip side, if you want to take more of a positive approach, what's one thing that you really see making a significant difference that you wish more organizations were doing?

Dr. Duchscher:

I am going to answer both. I think the first thing, we'll end on the positive note. The first thing that I see a lot of institutions doing that I would like them to revisit is not having a theoretical framework, not understanding that the resources that they commit to the newly graduated nurse need to be strategic. Otherwise it's a waste of their money and time and it's not really going to effectually change that experience of that newly graduated nurse. So I'd like to see more theory involved there and an attention to all the elements, not just the skill competency. Kind of related to that is what I'm starting to see more of across the country and that is this idea of clinical mentorship. They call them different things clinical mentors, clinical scholars, resource nurses but that team and that idea is often used in the float nurse context, so I don't tend to use it.

Dr. Duchscher:

But bringing back this is something I really wish organizations would do, and some of them I've seen. For instance, in Australia they call it wisdom at work and it's a program that they're they're implementing to bring back nurses who have left the workplace and they don't give them a workload, they are simply mentoring all the nurses on the unit with a focus on the newly graduated nurses. Those clinical mentors or clinical scholars, or whatever you want to call them, should be kind of trained the way that I would train the storm chasers, except these individuals are primarily supporting the new graduates in their clinical practice, but understanding that you can't support a new graduate with their clinical practice unless you understand what they're experiencing in their transition experience. So I would like to see this initiative take a hold in all areas of nursing across North America. That's what I'd love to see.

Nicole Weathers:

I love that and I think that what a great. You know, one thing that I've often talked about, as we see so many nurses retiring or leaving the workforce, is all the years of knowledge and experience and expertise that are going with them, right, and that we are losing that and we've got to figure out some way to capture that and harness that and put it in a bottle so that we've got it for the future, for these new graduates, and so what a great idea and a great way to continue to support them and giving back to the profession but also helping our new graduate nurses and those new to practice. That is a really amazing idea and I would love to see that as well.

Dr. Duchscher:

A lot of our senior nurses, even mid to later career nurses, left recently and we know we've had this tremendous attrition of our intellectual capital and our practice capital and a lot of them left because they were exhausted and felt, you know, devalued, underappreciated, weren't able to practice the way they wanted to. So this is also an opportunity to let them leave a different way. It's something I think we owe them. We need to bring them back and say, hey, you know we apologize, we didn't want you to leave. On that note, we want you to leave feeling really good about who you are as a practitioner and being able to share all that you learned. We know nursing is a highly tacit oriented profession. We need to pass that information on, and the only way to do it is from seasoned nurse to novice nurse. So I think it meets everybody's needs.

Nicole Weathers:

And I think that's a great place to end this episode of the podcast. Judy, thank you so much for your time today and sharing all of your valuable expertise and, as I said at the beginning, it's been such an honor to speak with you today and continue to learn from you.

Dr. Duchscher:

Well, thank you, Nicole. I feel exactly the same way and I hope we keep in touch over the time.

Nicole Weathers:

Wait. Before you go, I want to make sure you know all about our suite of resources you can use to support your new graduate nurses. Resources you can use to support your new graduate nurses. This includes our academy, a coaching program designed for organizations as they prepare for the implementation and ongoing sustainability of a nurse residency program. Work one-on-one with residency program experts to make sure your organization is residency ready.

Nicole Weathers:

Our clinician well-being course is an asynchronous online course that aims to enhance. The well-being course is an asynchronous online course that aims to enhance the well-being and resiliency of healthcare professionals, equipping them with the necessary psychological capital to navigate challenges inside and outside of work. Supporting nurses is another asynchronous online course for preceptors, mentors and coaches to learn the skills they need to support any new hire. Both of these offerings can be used as a standalone professional development opportunity or to augment any nurse residency program. And we can't forget about the program that started it all the online nurse residency program. This includes a comprehensive curriculum designed to support new graduate nurses, applying all the knowledge they learned in school to their practice. We focus on professional skills, personal well-being, competencies, and new graduate nurses even get the opportunity to create real change in their own organization. Offered completely online and in a blended format, this program is highly adaptable to all clinical practice settings. You can learn more about all of these programs and more of what we offer using the links in the show notes below.