Throughout the first year of nursing practice, negative emotions or being “out of the comfort zone” have been reported by new graduate RNs (NGRNs) in the literature. The phrase being out of the comfort zone does not accurately reflect the range of comfort experiences of new graduate RNs and thus precludes individualized and targeted support.
This article challenges the notion of a singular comfort zone and suggests that a spectrum of comfort is a more accurate reflection of new graduates' experiences. There is a need to competently and safely address the challenges experienced by new graduates during transition.
NGRNs report being out of their comfort zone for variable and extended amounts of time. On certain days, it is reported that they are out of their comfort zone for short periods. On other days, they feel out of their comfort zone for most of the time (Duchscher, 2008). The expression of “being in one's comfort zone” is defined by White (2009) as having the following principle elements:
The comfort zone is a behavioral state where an individual operates in an anxiety-neutral condition by using a limited set of behaviors to deliver a steady level of performance, usually without a sense of risk.
In accordance with the previous definition, the comfort zone is typically described as a neutral region of comfort, free of risk and challenge. Additionally, there is an array of positive and negative regions of comfort described in the literature (Brown, 2008; White, 2009). The amalgamation of these three regions of comfort is conceptualized as a spectrum of comfort in Figure 1.
Conceptual model: Spectrum of comfort.
Positive regions of comfort are characterized as the growth or learning zone, also called the stretch zone or the optimal performance zone (Brown, 2008; White, 2009). The negative region of comfort is experienced when an individual leaves the positive comfort region and moves into the panic zone or danger zone. In the negative region, feelings of being overwhelmed and panicked are often experienced and as a result performance suffers exponentially (Brown, 2008; White, 2009). The neutral region, where there is familiarity and little sense of risk, is placed off center, as White (2009) reflected that certain scenarios have the capacity to move individuals out of the neutral region and into the negative region of the comfort spectrum more quickly than others (Table 1).
Theoretical Framework Highlighting the Regions of Comfort Spectrum
Throughout the first year of nursing practice, negative emotions are often the norm, precipitated primarily by being overwhelmed by unexpected responsibility (Pinchera, 2012). The effects of these feelings of tension and resultant relief behaviors hinder social engagement and distort interpretation of any informal feedback received from members of the interprofessional team (Kim, Yeo, Park, Sin, & Jones, 2018). These perceived or real threats to the psychological self are purported to result in feelings of inadequacy and insecurity so severe they can cause the NGRN to resist seeking help or avoid asking critical questions (Krozek, 2017). Other symptoms can present, such as physical or psychological illness, crying, acting out, withdrawal, irritation, anger, and avoidance (Washington, 2012). These extraordinary stressors place significant demands on the NGRN's resources of energy and ability to perform well in the context of providing safe patient care. The phenomenon of “walking on thin ice” has been a description used to depict this way of being for many NGRNs (Liang, Lin, & Wu, 2018).
To address these concerns, increasing psychological capital can be beneficial (Kim & Yoo, 2018). In addition, observing successful role models, developing competency in nursing skills (Walker & Campbell, 2013), accessing supportive mentors (Kim & Yoo, 2018), and continuing exposure to the clinical environment have also been advocated. Successful overcoming of obstacles is essential to NGRNs' psychological capital and the subsequent resilience that ensues: “Studies have revealed that through the experience of a stressful event and overcoming it through being resilient, individuals emerged stronger, perform better, and become more confident and self-efficient” (Wahab, Mordiffi, Ang, & Lopez, 2017, p. 44).
Where resilience improves, reports of being in the negative region of the comfort zone spectrum are reported to reduce. The interplay between self-talk, relationships with others, and the organizational culture influence the comfort zone perspective (Dwyer & Hunter Revell, 2016). Camaraderie is considered an important factor to reducing stress in the health care environment (Wahab et al., 2017). Camaraderie requires an attuned social intelligence to effectively engage with others so that when experiencing panic, NGRNs are able to access an immediate circle of support (Walker & Campbell, 2013). These feelings of insecurity are likely to continue until NGRNs are more settled into their environment and have the requisite knowledge and skills to be more confident. Consequently, with improved interpretation of relationships and a more positive lens through which they view themselves, the new graduate begins to demand respect as a valued member of the team (Mansour & Mattukoyya, 2018). The aim of this article is to explore the spectrum of comfort as a determinant of success for NGRNs and recommend appropriate support to optimize learning and performance.
Grounded theory requires examination of the information collected and development of new theoretical frameworks (Glaser, 1967a). However, where it is discovered that a prior hypothesis fits the data with negligible distortion, verification or expansion of the theory is a conceivable outcome (Glaser, 1967b; Strauss & Corbin, 1990).
Thoroughness of the investigation was achieved by using the four criteria of Guba and Lincoln (1989)—believability, transferability, dependability, and confirmability. To provide believability, predetermined closed questions were used to gather information and open-ended inquiry was used to evoke richness of thought, emotion, and strategy. Meetings were translated verbatim. To help transferability, field notes were taken to supplement richness of the information and provide context to the setting (Charmaz, 2014). An audit trail is accessible for confirmability (Guba & Lincoln, 1989). Transferability is reflected in the rich depiction of the context in which the nine informants were situated and their various transition experiences. To provide reflexivity, interviews were shared between the investigator, who is a university researcher, and an accomplished interviewer who was about to embrace her transition to practice as an NGRN. The initial interview was undertaken with both investigators present to contextualize the questions and to ensure confirmability (Guba & Lincoln, 1989).
Ethics endorsement was provided by the Southern Adelaide Clinical Human Research Ethics Committee Clinical Human Research Ethics committee, and site-explicit endorsement was obtained from all health units. Sources were provided with a letter of introduction, an overview of the nature of the exploration, and a portrayal of expectations. Itemized questions were given to informants so consultation with partners, colleagues, or family could occur prior to giving consent. Informants were likewise educated that participation was voluntary, they could cease participation at any time, and they could decline to answer any question.
A cursory view of the data from this research has been analyzed and reported previously. However, the richness of data warranted further scrutiny. Since first publication, deeper analysis has revealed significant revelations about NGRNs and the spectrum of comfort in clinical practice. This separate examination uses grounded theory to investigate the spectrum of comfort experienced by NGRNs during their progress to proficient practice.
Nine NGRN informants volunteered to be involved from rural and metropolitan South Australia. Informants were individuals who had recently completed their transition-to-professional practice program. Table 2 provides a detailed record of every informant and their background using pseudonyms for confidentiality.
The results confirmed that NGRNs were challenged and that being in the negative region of the spectrum of comfort was an overwhelming feature of their early practice (Figure 2).
Reaction and response summary.
Overall, the themes identified were both in the positive and negative and regions of comfort. Negative themes were: Feeling Abandoned, Sometimes I Get Frightened, and Feeling Betrayed—Catching Hold. The positive themes were: Moderation of Emotions, and Letting Go.
Feeling Alone and Abandoned
Feelings of abandonment, a precursor to feeling frightened, were often reported and expressed in several ways. For example:
- I just felt like I had no one and I just felt very alone…. What am I going to do? But I pulled it together and I thought: Where else can I get help? So, I was just brainstorming: Who can I go to? What can I do?
- I did feel really really stressed and knowing that I had all these other patients I had to go to and I knew I couldn't really ask anyone else to pick up my patients because they were all in the same situation…maybe [with] another extra nurse with me, things would have been different.
- There was nobody to call on, which I did try and I wasn't supported.
Sometimes I Get Frightened
As a consequence of abandonment, coping with the newness, routine, and many expectations of the RN role made NGRNs feel frightened. These frightening feelings were expressed in different ways. Some found it difficult to articulate how they felt as the emotions would virtually rob them of their ability to speak. Others used descriptions that were emotive, such as:
- It was really horrible.
- You do freak [out].
- [An] adrenaline feeling in my bones.
- Eyes were boggling.
- Mass confusion.
For example, Rachel was allocated to a patient who was on a noradrenaline infusion she was unfamiliar with. Rachel did not know how to titrate the dose and described how stressed she felt when left to this responsibility without any prior education and support. She also made the decision to not be in this situation again:
And it was frightening…it was like, do I put it up or do I put it down? I have no idea—it was really horrible as I had no idea.
Similarly, Natasha was unable to address a serious problem with a patient because all of the senior staff were busy with another emergency. She felt a range of powerful emotions, including anger at being left in this dilemma as a first-year NGRN. However, she was mostly frightened at being abandoned:
I felt I suppose a range of emotions, from anger to despair, to almost breaking down and having a big cry—what am I going to do?
In a further example, and NGRN identified as Sandra was asked to relieve in an unfamiliar ward when her allocated ward did not have many patients. She had been working with children and the prospect of working with adults was frightening:
When I first got sent to an adult ward I freaked out…I got there and I just panicked. They were like “Can you go and feed this man that's had a stroke?” and I'd never looked after anyone that had a stroke—I was petrified and I went into the bathroom and I just cried and cried and cried, and I had a bit of a panic attack.
Feeling Betrayed: Catching Hold and Not Letting Go
Graduates reported they were often left in situations for which they were not prepared and felt betrayed, particularly when covertly allocated a patient who required care that was out of their scope of practice. Due to having a negative experience on one occasion, the NGRNs often made a pact with themselves that this would not happen again. It became instinctive to gain the attention of the RN or staff member who was handing off and not end the conversation until they were satisfied that their knowledge of the patient, equipment, and care required was complete. In this example, Rachel [all names are pseudonyms] demonstrates her concern at being left in charge of patients for whom she was not prepared for or informed of:
I won't let the [hand-off] person go until they tell me [how to manage this patient] before they leave and [so] they won't leave me in charge—I will not be left in charge of something that I don't know and be told “That's okay, they're fine you don't need to do anything.”
In the following scenario, a patient with chronic obstructive pulmonary disease was admitted to the emergency department; however, the senior staff attributed anxiety as the underlying cause of the symptoms being experienced. As a consequence, an unsuspecting Leslie (NGRN) was assigned to this patient. Not only did she feel distressed and confused but had difficulty gaining urgent assistance when the patient suddenly deteriorated:
He was just like staring with his eyes open, and the paramedic walked behind him and shone his penlight in his eyes and said, “Oh they're fixed and dilated.” So I went, “Oh holy crap, what do I do”—and it was just like this mass confusion. So the doctor was looking right at me because I was in ED [emergency department], so I called him over, and he didn't realize that it was urgent, so I called him over again, louder and I like clapped at him to try and make him come.
Others ensured they had a back-up person to provide support when feeling overwhelmed by a patient situation. In the following scenario, while questioning her own ability as a NGRN, Caroline was still willing to respond to this cardiac emergency patient, providing that a support person was nearby:
I have answered the ambulance radio and got the impression that I was going to be in charge of this patient... and you just think…am I ready for this? Am I able to respond appropriately and all the rest of it? But you do have [support]...even if its administrative support who are also nurses, you kind of…rush up to them and say...look I have got such and such coming through can you just come and be nearby…so that if I am out of my depth I can call on you.
Strategies NGRNs used to cope were primarily based around a change of mindset and being proactive in whatever activity they were involved. A positive mindset and being confident is a strategy specifically adopted by Caroline:
I do a lot of I think…positive mind…positive outcome sort of thing….a lot of you did well in your studies [so] you know a lot of stuff…you might not have the experience…but you know you have the knowledge base and you should be able to draw upon that…try it and reassure yourself that it is going to be OK.
Assuming full responsibility and being proactive to achieve safe patient outcomes was also important to Heather:
So I need to do this, I need to do this…so you kind of like had a plan in your head of what you needed to do and I think that kind of got me through.
Natasha was able to use her emotional intelligence to restore her comfort into the positive array. She was able to recognize her emotional state, interrupt her feelings of panic and adopt a strategic approach and renewed mindset:
Just work off one thing at a time, one step, if you can't get to the last step that's okay, as long as you've done your important things then you're getting there. You've only got so many hours in a day and you've got one pair of hands.
Letting Go: Restoration of Positive Equilibrium
Each graduate reflected on their progress and reinterpreted their experience and approach to developing competence and confidence. As a consequence of these insights, they developed resilience and assumed responsibility for their own performance and professional development. Jenny doubted her recording of blood pressure readings which she described as “a bit low” when the systolic reading was 85 mmHg. After reflection, Jenny made the decision to not always refer to others and to trust her own judgement:
So we had to call the MET [medical emergency team] and so I think, now I think back about it, I could've escalated it earlier, I could've been a bit more confident about it. So I guess in terms of comfort zone, I probably shouldn't have needed to get the senior RN to check the blood pressure, I could've just called the doctor straight away but it, I guess it comes with experience.
Heather was initially fearful of the intensive care unit; however, she turned the situation around:
I don't know everything but I'm willing to learn and I'm willing to put the time and the effort in so please feel free… I'm a sponge use me and abuse me. So they did and I think that's why I think I had such a positive first 6 months in the ICU [intensive care unit].
Alison was keen to reduce unpredictability when caring for her patients. As a result, she made the decision to restore equilibrium by being prepared as much as possible for any eventuality. Her research and increased knowledge was empowering:
- Like if I was not quite sure of this medical procedure… you could always go and look it up and find a bit more information…doing a bit more studying…a bit more research and knowledge is very empowering.
- Leslie made the decision to view the stress reaction to emergency situations as a normal phenomenon.
- I had a bad experience to start with, but then that primed me for the next time, which was a much better experience and I was a lot more functional. I think it's just exposure to these things that helps…it's always stressful and I think that's quite a normal thing.
This study confirms that being in the neutral region of comfort was not a familiar experience for NGRNs. As a novice member of the nursing profession, the NGRN is uneasy in many different contexts (Duchscher, 2009; Duchscher & Windey, 2018; Zheng, Lee, & Bloomer, 2016). Most were extremely driven to leave the negative region of the comfort spectrum after a short amount of time and were keen to restore a positive equilibrium as soon as possible (Herron, 2018). In instances where incomplete information was provided, many NGRNs felt betrayed and as a consequence actively chose to take charge when there was a patient handoff (i.e., where an unfamiliar patient diagnosis, piece of equipment, or procedure was encountered), the NGRN would catch the attention of the person performing the handoff and cling firmly onto this person, holding them in virtual “custody,” until their fears were addressed. As a result, panic was reduced and the NGRN was able to function more effectively (Pinchera, 2012).
Graduates who were less assertive felt alone. They were reluctant to consult other staff whom they perceived as too busy to help. The risk to patient safety and their own well-being was always present (Ankers, Barton, & Parry, 2018; Krozek, 2017; Liang et al., 2018). At times they had to desist from being overwhelmed and choose helpful thinking. Their emotional labor was at times draining but most NGRNs actively moderated their emotions to overcome feelings of being overwhelmed (Moran, 2012).
NGRNs were able to proactively establish a positive equilibrium in a number of ways. This included being proactive with their learning in anticipation of the patient situations that were likely to be encountered (Wahab et al., 2017) Reframing can be performed by adopting the perspective that being fearful in a critical situation is a normal response. This mindset enabled two NGRNs to view their inept response to an unfamiliar scenario as positive, as the prior experience enabled them to perform competently when confronted with the same situation on a subsequent occasion (Wahab et al., 2017). Embracing the perceived anxiety of being a novice in the intensive care unit environment was particularly helpful for one graduate, whereas other NGRNs reported that when feeling anxious or uncomfortable the strategy they instinctively used was to focus on talking openly with as many people as possible. Being honest with their experiences and allowing space to reflect and gain perspective was found to be beneficial in restoring a positive equilibrium. One new graduate with well-developed social skills found that interacting with patients was a positive way of relaxing when others around them were feeling uncomfortable (Walker & Campbell, 2013).
Experienced colleagues can do much to ameliorate NGRNs' fear and uncertainty during the first few months of practice. Planned oversight is an important consideration as stated by Ebright (2010): “What distribution of care delivery, or alternative assignment of RNs, would assure that every patient was assessed by an experienced RN every shift?” (p. 11). It is essential that purposeful support is provided, one that acknowledges the NGRN's limited experience, affords the necessary guidance, and is sensitive to the need for support and a growing quest for independence (Duchscher, 2008; Ebright, 2010; Gardiner & Sheen, 2017). There should also be a culture of camaraderie (Sedgwick & Pijl-Zeiber, 2015; Wahab et al., 2017) and encouragement of NGRNs to seek help from experienced staff when feelings of panic arise (Ebright, 2010).
Table 3 summarizes the NGRN spectrum of comfort experience. Each phase is accompanied by recommendations for self-support and support from experienced staff.
Spectrum of Comfort: Considerations and Support
Three negative regions were found within the spectrum of comfort: feeling alone, feeling frightened, and feeling betrayed. These reflect behavioral states that elicit a sense of risk and anxiety in response to a trigger event. Rachel's recount of panic after an incomplete handoff of a critically ill new patient on a noradrenaline infusion is an example of this. In these instances, experienced staff need to observe the practice of the NGRN, verbally signal their availability to assist, and ensure that handoff is complete. It is important to proactively ensure that all appropriate patient deterioration variables and medical emergency team considerations are included during handoff. With the support of experienced staff, the NGRN should feel confident that they have a complete grasp of the situation and have back up if required (Brown, Hochstetler, Rode, Abraham, & Gillum, 2018; Walton, Lindsay, Hales, & Rook, 2018).
The two positive regions within the spectrum of comfort—moderation of emotions and letting go—reflect a behavioral state in which a change of mindset by the NGRN avoids panic and elicits a moderated response to the trigger event. This deescalation allows the NGRN to assess the patient situation effectively and safely. As the new graduates gain exposure to the rigors of their particular clinical environment, they become familiar with their personal and workplace triggers and begin to develop a positive equilibrium in which they become more proactive with learning new skills to reduce unpredictability. It is in these phases that staff can provide a positive reassuring environment that is responsive to stress reactions and encourages personal and professional development.
The neutral region of the spectrum of comfort is included in Table 3. It is a no growth zone where performance is steady and there is little anxiety. Complacency can adversely affect patient safety. Paradoxically, this neutral region is routinely called the comfort zone, a zone in which most people want to inhabit constantly. Being out of the comfort zone is viewed as undesirable and is a perspective that needs to be challenged.
In this study, nine NGRNs volunteered to be interviewed. In their study of interviews and qualitative analysis, Guest, Bunce, and Johnson (2006) found that themes and variability were usually identified after six interviews and saturation was anticipated after 12 interviews. The original choice of data collection was to be face-to-face via interview; however, it became necessary to interview some participants via telephone for convenience. In order to not compromise the study with this variable, resources on effective telephone interviews were accessed (Wilson, Roe, & Wright, 1998) and as a consequence the richness of data was preserved. Interviews took place throughout an 18-month period because of limited access to informants and access to venues with respect to ethics approval. It is unlikely that the health cultures would change considerably throughout the extended interview period; however, this is a possibility. The prior nonbaccalaureate practical nursing history of many of the respondents may influence the outcomes. However, it is usual for practical nurses to require the same level of support as other RN graduates and hence conceal their past experience:
Surprisingly, GNs [graduate nurses] who had previously practiced as ENs [practical nurses] preferred not to be identified as having previous nursing experience. This was because they feared being treated by their nurse managers as already capable of practicing as RNs. In reality, this group of new RNs needed support like any GN.
The age of the participants also needs consideration. Some informants were 20 to 30 years old, others were in their 50s. The average age of participants was 35 years. This demographic is consistent with the various studies reviewed (Cubit & Lopez, 2012). However, it is slightly higher than the average entry level of approximately age 26.9 years in Australia (Gaynor et al., 2008, p. 16) and age 30 years in the United States (Allied Staffing Network, 2017). The average nursing workforce age is 44.4 years in Australia (Australian Institute of Health and Welfare, 2015) and age 51 years in the United States (National Council of State Boards of Nursing, 2017). Further details of the life context of the informants are provided in Table 2. The result of such multi-level influences was studied in detail by Dwyer and Hunter Revell (2016) and found that undergraduate preparation was the most significant variable and “relatively few demographic variables consistently influenced transitional outcomes” (p. 113). In addition, all of the informants participated in a standardized graduate program for government hospitals, which included orientation, preceptorship, and clinical rotations. However, it is recognized that interpretation of the curriculum, organizational culture, and resources available when implementing the graduate program could vary at different locations (Table 2). Further research including systematic evaluation with control groups of the interventions inherent in graduate programs is recommended in order to determine their effectiveness.
This study challenges the notion of a singular comfort zone and suggests that a spectrum of comfort is a more accurate reflection of NGRN experiences. A number of regions within the spectrum have been identified. These regions are not linear but recursive as different situations arise. The three negative regions on the spectrum include feeling abandoned, feeling frightened, and feeling betrayed. In response to the resulting panic and distress, clinicians with more experience need to be aware of these reactions and respond effectively to ensure the emotional well-being of the NGRNs and provision of safe patient care. The positive regions within the spectrum include taking charge through proactively seeking support and critical clinical information, moderation of emotions, and finally letting go as the NGRNs begin to change their mindset and restore a positive equilibrium. Navigating the spectrum of comfort is a significant challenge for NGRNs but with support they can succeed. These findings may assist NGRNs and clinicians with further contextualizing the transition experience and nature of support required by graduates.
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Theoretical Framework Highlighting the Regions of Comfort Spectrum
|Region of Comfort Spectrum||Characteristics||Expected Performance|
Confident and happy
Anxiety free and familiarity
Learning and achievement
Circle of safety implicit
|Family to support||Yes||Yes||No||No||Yes||Yes||No||No||No|
|Prior nonbaccalaureate practical nursing qualifications||Yes||No||Yes||No||Yes||Yes||Yes||Yes||Yes|
|Practical nurse in the same institution previously||No||No||No||No||Yes||Yes||No||No||No|
|Graduate nurse transition program||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes|
|Rural or city||Rural||Rural||City||Rural||Rural||City||City||City||City|
|Size of health service (beds)||(30–60)||(30–60)||(300–499)||(30–60)||(30–60)||(300–499)||(500–700)||(500–700)||(500–700)|
|Clinical rotations||Aged care, General medical– surgical, and Emergency||General medical– surgical, Renal, and Chemotherapy||General medical and Day surgery||Operating room, General medical surgical, and Emergency||General medical/surgical and Operating room||ICU and Medical ward||Stroke ward, Neurology, and Neonatal||Hematology and ICU||Hematology and ICU|
|Hours worked per week||32||32||32||32||32||24–32||32||32||32|
Spectrum of Comfort: Considerations and Support
|Spectrum of Comfort||Phases||Comfort Considerations||Self-Support||Suggested Support From Experienced Staff|
|Negative||Feeling alone and abandoned||Left alone (i.e., no idea what to do)||Recognize feelings as normal||Watch over
Plan to care for the NGRN and provide oversight.
|Negative||Sometimes I get frightened||Afraid for themselves and their patients.||Recognize feelings as normal||Assist
Be available to assist as necessary.
Catching hold and not letting go.
|Refusal to be denied support and critical clinical information||Expand circle of support||Rescue
Proactively ensure that all medical emergency team considerations are provided and educate when transferring care to a NGRN.
|Positive||Moderation of emotions||Adoption of strategies to cope with emotions||Positive mindset and perspective taking||Provide hope
Observe for stress reactions
Provide exposure to new skills, support, constructive feedback, and encouragement.
Provide emotional support.
Restoration of a positive equilibrium.
Trusting own judgement
Change of mindset and perspective
Be proactive with learning and skills
Encourage development of skills through planned exposure to critical situations and debrief.
|Neutral||Little anxiety||Feeling confident
Steady level of performance
Be aware of complacency
Continue to be proactive
|Prepare for potential critical scenarios|