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Traditionally, the new graduate registered nurse (RN) transition has included a didactic and skills-based orientation accompanied by a period of preceptored practice. However, these methods do not ensure that new RNs are in a state of reduced anxiety to fully interact with their new environment. Transition to practice may cause anxiety, and the new graduate RN may perceive moderate to severe stress. One method of stress reduction is the use of guided imagery, which has shown strong potential with a variety of populations undergoing stressful events. Today, new graduate RNs expect institutions to facilitate orientation to their new employment settings and assist in the transition to their role as a professional nurse. This article proposes a model that incorporates guided imagery for refining the new graduate RN transition process. The model can be adapted for use in the context of orienting other adult learners to unfamiliar practice situations.
The nursing profession represents the largest proportion of the health care work force in the United States, and nurses perform front-line work with patients. Therefore, skilled, competent nurses are critically important to the transformation of the nation's health care environment. After a 2-year initiative to assess the nursing profession, the Institute of Medicine (2010) recommended higher levels of education, training, and lifelong learning to meet the expectations of expanded registered nurse (RN) roles that will accompany health care reform. The transition of a new graduate RN to an independently functioning RN requires the new nurse to leave the familiarity and support of the nursing educational program and enter the world as a practitioner.
The transition from graduation to practice is often stressful as new graduate RNs realize that they are without the previous academic support to which they have grown accustomed (Duchscher, 2009). Perceived lack of support related to discrepancies in the characteristics of the work environment compared with nursing expectations contributes to job stress and new graduate RN turnover (Kovner et al., 2007; Yeh & Yu, 2009). In a longitudinal study of newly licensed RNs in 15 states, 26% of new RNs left their first employers within 2 years, and even in the midst of an economic recession, 13% left their jobs within the first year (Brewer, Kovner, Yingrengreung, & Djukic, 2012). At an estimated cost of $82,000 to $88,000 per nurse replaced, high new graduate RN turnover is costly for hiring institutions as well as damaging to the esteem and self-perception of the unsuccessful new hires (Jones, 2008). To address this problem, the Institute of Medicine (2011) and the Joint Commission (2010) recommended nurse residency programs that expand and enhance the orientation period for new graduate RNs and for experienced nurses transitioning to a different area of practice. An expanded and enhanced orientation period facilitates the transition for both the new RNs and the organizations that hire them, as well as the patients who depend on safe, quality nursing care. However, the issue of what actually helps the new graduate RN to transition to practice remains elusive. According to the work of Benner, Sutphen, Leonard, and Day (2010), the path from novice to expert requires novice nurses to master technical skills before developing expertise. Methods to assist new graduate RNs to overcome their own stress help them to gain competency during the transition period.
This article proposes the integration of guided imagery into components of the new RN residency program. Guided imagery is a mind-body-spiritual technique that directs one's imagination toward a relaxed, positive state that promotes health (Achterberg, 1985). With this technique, a practitioner uses spontaneous speech or follows a script to purposefully redirect or “guide” the participant's imagination to create positive mental images to aid in relaxation, focused concentration, stress reduction, and a sense of empowerment, and ultimately to escape from negative thoughts (Roffe, Schmidt, & Ernst, 2005). Soothing background music often accompanies the spoken word of the guided imagery sessions. Often participants are guided to imagine themselves in an environment that is peaceful, comfortable, and safe. In guided imagery, the body responds physiologically to the image in the mind as if it were reality (Naparstek, 1994). Although visual images are most often invoked, Achterberg, Dossey, and Kolkmeier (1994) recommended that guided imagery should include all of the senses and accommodate individual preferences because a significant number of individuals are unable to successfully visualize images. Guided imagery can be delivered to participants cost-effectively through the use of professionally produced audio recordings that include directions for use, so educators do not need lengthy training to introduce guided imagery into an RN residency program. The sessions can be delivered one-to-one or in groups. The recorded scripts facilitate participants’ ability to practice the technique at their choice of location and time. With practice, participants can often learn to evoke positive images in their minds without the guidance of a script.
Guided imagery has been shown to have powerful effects in a variety of settings and populations. Studies have found significant decreases in systolic blood pressure, pulse rate, and perceived stress levels among health care workers after guided imagery sessions (Kruschke, 2008). Guided imagery has been used in nursing practice to reduce patients’ anxiety before invasive procedures and also to decrease postoperative pain (Tusek, 1997). It has also been used to reduce stress, improve immune function, increase feelings of empowerment, and promote well-being (Roffe et al., 2005). Guided imagery has been used in the field of sports psychology as a means to improve skill performance (Contrades, 1991).
A critical review of the literature suggested that guided imagery could be used to facilitate new graduate RNs’ transition to professional practice. This article discusses how guided imagery can be used as a mediating factor in providing new graduate RN orientation. The use of guided imagery is proposed to augment new RNs’ orientation by decreasing orientees’ stress levels and facilitating the transition from novice to competent professional nurse.
Because guided imagery is frequently associated with facilitating coping during stressful procedures, a critical review of the literature was undertaken to identify the conceptual and empirical uses of guided imagery for new graduate RNs and student nurses. The author made the assumption that guided imagery will facilitate the novice's successful accomplishment of nursing tasks. A thematic analysis across the selected literature was undertaken.
A variety of terms have been used in the nursing literature to represent forms of literature searches. In this article, an integrative review is used, which is systematic in approach and qualitative in method. In an integrative review format, primary studies are combined in a narrative description so that overall conclusions can be drawn. Furthermore, themes or common ideas that are found across the literature are categorized into general summative statements.
The inclusion criteria consisted of the following: (1) case reports, descriptive studies, or clinical trials that addressed the use of guided imagery in promoting success in learning among new graduate RNs or nursing students; (2) interventions that addressed the use of imagery and transition as applied to new graduate RNs or nursing students; and (3) review articles. Only peer-reviewed journal articles that were published in English were selected. A decision was made not to place limits on the time of publication to identify all uses of guided imagery in terms of nursing education.
Initially, a search of the literature was conducted with the terms “imagery and transition.” Preliminary searches were conducted via the CINAHL and Academic Search Premier databases. The CINAHL database yielded four relevant articles on imagery and nurses in transition. The same terms were then applied to the Academic Search Premier database, which yielded 149 articles; however, none of the new articles met the inclusion criteria.
An attempt was made to expand the search via the previously searched databases by using additional search terms consisting of combinations of “imagery, visualization, guided imagery, and stress management” WITH “transition, nurse, nursing education, and new graduate.” The predominantly representative articles addressed the concepts of guided imagery and stress. Thus, a decision was made to use the terms “guided imagery and stress,” and this search resulted in 262 potential citations via CINAHL and Academic Search Premier, 16 of which appeared relevant to nurses or nursing students. An additional four articles were identified through the reference lists of retrieved articles previously identified in the search.
The education of nursing students bears some relationship to the orientation practices of new graduate RNs, so additional search terms consisting of “guided imagery AND [nursing students OR nurse practice]” and “imagery AND nursing performance” were used. These latter searches resulted in seven unduplicated empirical articles predominantly related to the effect of imagery on the acquisition of nursing skills.
Finally, the PsycINFO database, dissertations, and the Cochrane Review were searched to yield more relevant articles. Several promising abstracts of articles and dissertations published between the 1980s and the 1990s were found. Of these, six were not available electronically but were accessed via interlibrary loan.
The culmination of these search strategies resulted in 37 citations. After the abstracts of the retrieved citations were reviewed for eligibility based on study inclusion criteria, a total of 12 articles were retrieved and included in the final sample. These 12 articles were the only ones that specifically used guided imagery for stress reduction in a population that included nurses or nursing students. The coauthor subsequently repeated the search strategies and article selection to ensure that no relevant studies were missed.
Each article in the sample was read in its entirety, and data elements were extracted and entered into a matrix (Table A, which appears as supplemental material in the online version of the article), according to the method of Garrard (2007). Data elements collected included author(s), publication year, purpose, intervention modality, outcomes measured, study design, sample, level of evidence, results, and comments. A level of evidence was assigned according to the method of Stetler et al. (1998), in which strength of evidence is rated on a scale of I to VI, with I being the strongest level of evidence, and quality of evidence is rated on a scale of A to D, with A being the highest quality of evidence. Only studies that contained clear descriptions of methods and analysis procedures, including power calculations or justification of sample size, were given a rating of A. Studies with a rating of D contained at least one significant methodological flaw that raised concerns about the believability of the results (Stetler et al., 1998). Various themes were noted across the articles.
Guided imagery and other relaxation strategies were used to reduce stress in the studies. The results of most studies showed either a reduction in stress (including proxy measures for stress) in the participants or participant evaluations that indicated that the intervention was effective or beneficial. Posttest improvement in skill mastery or examination scores was mixed.
Furthermore, guided imagery facilitated learners’ outcomes, as evidenced in the studies involving nursing students. Most of the guided imagery studies addressed students’ acquisition of psychomotor skills or the management of stress or anxiety.
The guided imagery used in the studies was divided into two major types: mental practice imagery and relaxation-focused imagery. One type of guided imagery seeks to enhance performance, and the other type seeks to reduce stress. Some studies used a combination of these or used them with other modalities, such as progressive muscle relaxation (Doheny, 1993), meditation (Kvale & Romick, 2000; Tsai & Crockett, 1993), hypnosis (Lindop, 1993), stretch-release relaxation (Yung, Fung, Chan, & Lau, 2004), physical practice (Bucher, 1993), and psychosynthesis (Kvale & Romick, 2000). Therefore, major differences in the findings may have been affected by these variations in the conceptualization of guided imagery.
Mental practice imagery is a technique that is widely used in sports psychology to help participants to acquire or enhance athletic skill performance. In mental practice, participants imagine the experience of performing a skill in great detail, while mentally working out problems before its actuation (Contrades, 1991). In the nursing research studies identified, mental practice was primarily used to reduce anxiety surrounding the acquisition of a new psychomotor skill (Bucher, 1993; Doheny, 1993; Speck, 1990; Wright, Hogard, Ellis, Smith, & Kelly, 2008). Bucher (1993) found significantly better skill performance in the group using both physical practice and mental practice compared with the group using mental practice only. Doheny (1993) tested four groups: control, mental practice, progressive muscle relaxation, and mental practice combined with muscle relaxation. This study also measured the degree of each participant's ability to generate vivid mental images. Doheny (1993) found that high imagers were more likely than low imagers to score an acceptable skill performance, regardless of treatment group. Speck (1990) found significantly lower self-reported anxiety levels in the treatment group, but skill performance did not differ significantly from that of the control group. Wright et al. (2008) found that students who received mental practice imagery training for measuring blood pressure performed better than those who did not.
In four studies, relaxation-focused guided imagery was found to induce a relaxed state of mind to reduce stress or anxiety (Kruschke, 2008; Stephens, 1992; Tsai & Crockett, 1993; Yung et al., 2004). Kvale and Romick (2000) used psychosynthesis, a method employing relaxation of the mind and body, followed by visualization of elements of the student's transition process to the professional nursing role. Afterward, participants drew pictures describing what they imagined. Donovan (1981) found significant improvement only in depression, one of six stress-related variables, but noted that participants with poor coping skills showed the most improvement after relaxation-focused guided imagery training. Lindop (1993) evaluated the effectiveness of a stress management program that included relaxation, imagery, and hypnosis. Most of the participants found the interventions in these three studies beneficial.
In a review article, Contrades (1991) showed that reducing stress can lead to enhanced performance. In this study, guided imagery was used to reduce anxiety levels and mental practice was used to improve skill performance. The author reported that the students had mixed reactions to the guided imagery. However, students who used mental practice as well as physical practice when learning psychomotor skills in the laboratory setting reported less anxiety, more confidence, and more proficiency in performing those skills in the patient care setting.
The reliability and validity of this analysis may be affected by the intervening (confounding) variables. The confounding factors include the following: (1) variance in the vividness of imaging ability across individuals, which needs to be measured or controlled; (2) variance in personal preferences (auditory, visual, tactile, or ol-factory images); and (3) variance in the duration and frequency of the guided imagery intervention and the amount of interest sustained by the participant throughout the sequence of sessions.
In the articles listed, participants were either nursing students or experienced nurses, with the exception of one study by Kruschke (2008) that included 67% experienced nurses and 33% other health care professionals. Most of the participants in the studies were undergraduate student nurses (Bucher, 1993; Contrades, 1991; Doheny, 1993; Lindop, 1993; Speck, 1990; Stephens, 1992; Wright et al., 2008). One article studied nurse-midwifery students (Kvale & Romick, 2000), and studies by Donovan (1981), Tsai and Crockett (1993), and Yung et al. (2004) included experienced nurses as participants.
Research took place primarily in the United States, but also in the United Kingdom and China. Perception of stress may be influenced by cultural differences, and there may be disparities between the types of stress experienced by nurses in clinical settings compared with students in educational settings. In addition, differences in cognitive development, maturity, and life experiences among the different sample populations (student nurses, graduate nursing students, and practicing nurses) may influence the perception of stress. Finally, the individual participant's ability to visualize was cited as a strong indicator of the efficacy of using guided imagery to improve skill performance (Bucher, 1993; Doheny, 1993; Wright et al., 2008).
A theoretical perspective guides how the researcher perceives the issue and delimits the variables for study. Most of the articles omitted mention of a theoretical approach. Of those that did mention a theoretical perspective, none were the same. Having mixed or missing theoretical approaches means that the selection of concepts under study may vary widely across empirical works. In other words, the lack of consistency across concepts represented by the findings may yield uncoordinated practice recommendations.
The methodological approach for a few articles included descriptive and correlational studies (Kvale & Romick, 2000; Lindop, 1993). One was a literature review (Contrades, 1991). Most of the studies, however, used tighter controls in their designs (e.g., quasi-experimental or experimental approaches) (Bucher, 1993; Doheny, 1993; Donovan, 1981; Kruschke, 2008; Speck, 1990; Stephens, 1992; Tsai & Crockett, 1993; Wright et al., 2008; Yung et al., 2004). Tightly controlled designs across studies result in a lower proportion of confounding issues potentially influencing the study outcomes. However, for topics such as the one for this article, study designs with less control (e.g., descriptive and correlational studies) play a significant role in concept clarification. Clarification of the concepts is important to ensure similarity in how the idea of “guided imagery” is measured in subsequent research.
Compared with the wealth of literature showing the success of nurses using guided imagery to help patients overcome anxiety and stress, there is surprisingly little evidence of the application of guided imagery to aid nurses in combating their own stress. In particular, there is a large gap in the literature regarding the use of guided imagery to empower the new graduate RN to transition to the role of professional nurse, recognized widely as an especially stressful period of a nurse's career. Although some literature has been published on the use of guided imagery with students in nursing school, mainly to augment mastery of skill sets, few published research articles were identified that describe this technique as a means to proactively combat stress in their eventual workplace.
The literature shows that guided imagery is used for stress reduction as well as to enhance performance. However, few studies show both stress reduction and performance enhancement. Research evidence is needed to identify directional relationships among stress reduction, mental practice, and improved new graduate RN performance in health care settings. Considering the state of the science and the potential applicability of guided imagery to the mastery of new skills and roles, a model to enhance the transition process of new graduate RNs is proposed.
Based on the evolution of salient themes in the literature to support the use of guided imagery in orientation, a model was developed to illustrate the use of guided imagery to help new RNs overcome their own stress. This model is suggested by the literature profiled by the current review. The model proposes the use of guided imagery to achieve mastery of the new graduate RN transitional phase. The Figure shows the model, in which guided imagery mediates the relationship among individuals’ perceptions of the new graduate RN transition process, practice proficiency, and mastery of the transition period outcomes.
The new graduate RN transition period is widely regarded as a highly stressful time in a nurse's career. Facilitating the new graduate RN's mastery of the transition process from student to professional RN is the ultimate desired outcome of providing guided imagery for stress reduction and performance enhancement. As nursing practice occurs in a shared context with other staff, patients, consumers, and health care administrators, the successful transition of the new graduate RN will affect the health care delivered on individual, unit, interdisciplinary, and institutional levels (Table).
Implementation of the model must include orientees’ self-assessments of what they perceive as threatening or challenging in terms of orientation or practice competencies. A prerecorded guided imagery program would ideally be introduced within the first few weeks of the nurse residency or orientation program for new graduate RNs. The Sidebar shows recommendations for the use of the model to guide new graduate orientation. The initial session would be introduced to the entire group, and a CD/DVD or audio file would be given to each nurse for continued use throughout the residency/orientation program at least three times per week during non-work hours. Scheduled weekly or monthly educational sessions would include further self-assessment of new or ongoing stress and challenges. The guided imagery program would be continued to aid in promoting well-being among the participants and to reinforce its effect over the entire residency/orientation period. Guided imagery also would be used to enhance learning in sessions where new skills are taught to enhance practice proficiencies. This type of guided imagery session could be offered individually or to groups, as appropriate, depending on the skills being taught. Such approaches are similar to the use of guided imagery for the athlete who is undergoing training in sports applications.
A 360° type of evaluation is ideally needed to evaluate this type of model. Traditionally, 360° feedback is a tool that provides employees the opportunity to receive performance feedback from supervisors and peers, reporting staff members, coworkers, and customers. With regard to the proposed model, feedback may be obtained from the different levels of interaction taken on by the new graduate RN.
In light of current health care costs, lower-cost informal approaches may be used alongside more formal evaluation approaches, such as surveys of self-reported stress, empowerment, confidence, and skill proficiency at the end of the residency/orientation program. Pairing the new graduate RN with a more experienced preceptor who has training in the use of guided imagery will reinforce this approach and provide an informal level of support.
In addition to augmenting the orientation of the new graduate RN by using guided imagery, these techniques may be used for nursing students, for practicing nurses who require updating of skills, or for nurses who are taking on new roles. Often the learner is asked to provide a return demonstration of the new skill. Reviewing the skill by using guided imagery techniques before the learner performs the return demonstration may further build individual capacity for successful learning.
For many, the new graduate RN transition is stressful. The Institute of Medicine's (2010) The Future of Nursing report recommended actions to support completion of a transition to practice program (nurse residency) in the workplace after graduation from a prelicensure nursing program. An important educational component of a nurse residency program is stress management. Currently, no standardized stress reduction training is provided to new graduate nurses. Guided imagery and other stress reduction techniques may reduce that stress. Guided imagery has the potential to serve as a mediator between the institution's attempts to provide a supportive orientation environment and the perception of proficiency of the new graduate RN. Teaching these techniques early in a nurse's career may provide a lasting means for stress reduction, enhancing job satisfaction and retention over time.
A CD/DVD or audio file is used to guide participants’ imagination to places or situations that will make them feel peaceful, safe, relaxed, and secure.
The CD/DVD or audio file may use gentle background music to create a relaxed atmosphere and help avoid distractions.
Participants may be asked to imagine a positive outcome to a stressful orientation situation, such as competence in completing the steps of a complex procedure or in implementing an institutional protocol.
While the participant focuses on the imagined situation, sensations and feelings, such as strength, competence, and confidence, are invoked.
Boehm, L. B., Tse, A. M. (2013). Application of Guided Imagery to Facilitate the Transition of New Graduate Registered Nurses. The Journal of Continuing Education in Nursing, 44(3), 113-119.
The authors have disclosed no potential conflicts of interest, financial or otherwise.
Ms. Laura B. Boehm, University of Hawaii at Manoa School of Nursing and Dental Hygiene, Department of Nursing, Honolulu. Hawaii Community College, Hilo, Hawaii.
Dr. Alice M. Tse, University of Hawaii at Manoa School of Nursing and Dental Hygiene, Department of Nursing, Honolulu, Hawaii.