Reflective practices date back to the Greek philosophers Aristotle and Socrates (Contreras et al., 2020; Miraglia & Asselin, 2015). The concept of reflection was expanded by the philosopher John Dewey, who believed one does not learn simply through experience but rather by reflecting on one's experiences (Miraglia & Asselin, 2015). Later, Donald Schon examined the impact of reflection on professional practice (Miraglia & Asselin, 2015).
More recently, reflection has been ascribed as a crucial component in professional nursing practice (Miraglia & Asselin, 2015). Reflective learning in nursing is a deliberate action of thinking critically about a clinical experience and recognizing insights that could help shape future practice (Buchwach & Hill, 2017). Reflective learning is appropriate for many levels of nursing (Billings & Halstead, 2020) but may be especially beneficial when incorporated into nursing orientation, preceptor programs, and nurse residency programs (Buchwach & Hill, 2017). Through the practice of reflection, the learner has the opportunity to explore personal feelings, beliefs, assumptions, and values (Miraglia & Asselin, 2015).
Verbal reflection as well as written reflection can be useful in guiding nurses to examine their own thoughts, beliefs, values, and practices. The ability to reflect on your own thoughts is often known as metacognition and a concept of the cognitive learning theory (Bastable, 2019). The cognitive learning theory is used in both education and counseling and focuses on what is going on inside the learner (Bastable, 2019). Although reflection is often thought to be a natural process, Miraglia and Asselin (2015) propose that it is a developed skill that should be taught.
One group who may benefit from education regarding the method and benefits of reflection is new graduate nurses. The transition from student nurse to professional nurse is often riddled with intense stress, causing new graduate nurses to be particularly vulnerable to burnout (Blakely & Jackson, 2016). New graduate nurses describe feeling anxious, overwhelmed, inadequate, and insecure throughout the first year of practice. These emotions were displayed in pediatric oncology new graduate nurses after experiencing what Linder (2009) referred to as nadir experiences. The unforeseen loss of a patient, devastating treatment effects, and lack of colleague support were defined as nadir experiences. In a study of six new graduate nurses' lived experiences over their first year of practice in a pediatric oncology unit, many themes arose including role development, unique practice, and personal reflection (Linder, 2009). Findings emphasized supporting new nurses beyond the acquisition of skills and knowledge and providing opportunities for personal reflection during orientation as essential components to ensure retention and future success within the subspecialty. Reflecting on stress has the potential to decrease stress. In another study, new graduate nurses were asked to write a reflective story at the end of the first year of practice (Fowler et al., 2018). The themes expressed in the reflective writing included teamwork, gratitude, asking questions, the art of nursing, and change (Fowler et al., 2018). The themes identified through these studies can serve as a guide to help shape first-year-of-practice programs, often known as nurse residency programs.
The Oncology Nurse Residency Program began in 2012 (inpatient), with the first group completing the program in 2013. The Oncology Nurse Residency Program was expanded to include the ambulatory setting in 2018. This year-long program currently consists of didactic instruction, skill competencies, Clinging Rigidly to Outdated Care projects, reflection, and legacy letter writing. Legacy letters (started with Cohort 10 in 2017) are written by the nurse residents completing the program in the form of a message to future nurse residents, reflecting on aspects of the experience such as "what I wish I knew" or "what I learned." Quantitative data, such as retention, has been analyzed since its inception; however, there has not been any qualitative analysis of the program (i.e., legacy letters), which can provide an understanding of the experience by nurse residents during their transition year and lead to program improvements.
It is important for new graduate nurses to reflect on their time in the residency program to identify strengths and weaknesses and make sense of the experience for personal and professional growth (Koshy et al., 2017). Reflective practice during a nurse residency program fosters self-awareness through personal exploration of thoughts and emotions and assists in building confidence (Bolden et al., 2011). In addition, reflection demonstrates professional growth through examining past patient experiences. Previous studies on nurse resident reflection were simply stories and not letters to the next group of nurse residents. This study adds to the body of knowledge of nurse residents' perceptions of their experiences and subsequent advice that is worthy of passing along to help ease the transition of future nurse residents. The purpose of this qualitative study was to identify and describe messages communicated in nurse residents' legacy letters at the conclusion of a year-long nurse residency program at a National Cancer Institute-designated comprehensive cancer center. The following research question guided this study of nurse residents' reflections at the conclusion of their program: What are the common messages nurse residents communicate in their legacy letters?
METHODS
Design and Setting
This study was a retrospective, qualitative descriptive analysis of legacy letters written by oncology nurse residents at a National Cancer Institute-designated comprehensive cancer center based in the southeastern United States. The approach seeks to discover the who, what, and where of experiences and gain insights into a phenomenon that may lack full understanding (Kim et al., 2017). Investigators sought to understand the reflection of nurse residents at the conclusion of their residency program in their written messages, known as legacy letters.
Approval was obtained from the center's nursing research and innovation council. The study was also reviewed by the center's scientific review committee and Advarra Institutional Review Board.
Sample
Currently, there are three nursing cohorts each year. The majority fulfill their residency in the inpatient setting and at the main campus. At the time of the study, there were 73 legacy letters in an existing database on the center's intranet. Letters were screened and blinded for confidentiality purposes by the principal investigator, who is most familiar with the letters, prior to team members reading and abstracting themes and subthemes.
Initially, 30 letters were selected for coding using a random number generator (calculator.net/random-number-generator.html). In order of the cohorts, 10 were selected from the first third of letters (Letters 1-24), 10 from the middle third (Letters 25-48), and 10 from the last third (Letters 49-73). This ensured a range of letters from the conception to most recently graduated nurse residents.
Thematic Analysis
The legacy letters were reviewed by the three members of the investigative team for common themes used to describe their messages, such as "what I wish I knew" or "what I learned." A qualitative thematic analysis was the selected approach for analyzing the responses to these open-ended questions (Vaismoradi et al., 2013). This approach was appropriate because the investigators were attempting to analyze the narrative messages of nurse residents in the form of legacy letters. Regular meetings were held for the three members of the study team involved in the thematic analysis. The team members independently reviewed the letters first then together. All letters were read, reread, and coded in order to become familiar with the data; identify initial codes; and find, review, and refine the themes. Any discrepancies and redundancy of the codes were discussed until consensus was reached and saturation met (Creswell & Plano Clark, 2018). These steps helped ensure quality and rigor of the analysis. No additional letters were required for analysis.
RESULTS
The sample consisted of 30 letters. Four themes describing or elaborating on features of the experiences, advice, and lessons learned of nurse residents transitioning into practice were identified. Two of these themes were interpersonal (knowledge and skills acquisition, and connection with patient/family), and the remaining two were intrapersonal (dynamics of emotions and self-care). See Table 1 for a summary of themes and subthemes with frequency counts.
Theme 1: Knowledge and Skills Acquisition
The most frequently endorsed theme centered around learning by nearly all residents (n = 28). Learning is evident when there is a change in knowledge, skills, and/or attitudes (Bastable, 2019). The graduating nurse residents highlighted this theme of knowledge and skill acquisition with a strong emphasis on asking questions, utilizing resources, and learning from mistakes.
Subtheme: Ask questions
Learning is a continuous process, and asking questions was both highlighted and encouraged. "We want you to always ask questions. Nursing is a profession of constant growth and learning. I am always learning and somedays I still feel like I know nothing!" noted one resident (ID 19). Whereas another resident related its necessity for this journey, "Ask questions, be curious, and continue to learn as you progress through this journey." Encouragement included that there are no stupid questions and it is okay to ask for help as everyone is willing to help. One resident declared, "do not be afraid to become vulnerable and ask them anything you may be having trouble with." Another summarized her advice as,
Ask, ask, and ask again until you get it right! I was timid and embarrassed to ask for help in the beginning of my nursing career. However, I have since learned even the most experienced of nurses ask for help. My clinical leaders have become my family, you will not be criticized for calling them all night long if need be.
Subtheme: Utilize your resources
There was a strong emphasis on utilizing resources, both human and material, as part of knowledge and skills acquisition. Two residents stated "become a sponge," with one elaborating on "do not take this residency program for granted. I hope you are able to walk out of each residency day with learning at least one skill or obtaining one snippet of knowledge you can bring back to your unit" and the other "take in every second of being a nurse." Similarly, another resident noted, "Take advantage of the residency program, especially the simulation days. The more hands on you are the more it will benefit you. [The coordinator and facilitator] are amazing resources and will teach you so much."
Human resources included the importance of finding someone to connect with on a professional level. Whether that be a mentor or someone to lean on the importance of venting was advised. One resident stated, "Find someone you can vent to at work. As hard as your family members and friends try to understand what you go through at work, no one truly understands like your coworkers do." Another resident shared,
Find your go to person/people while working here. As important as it is to provide good patient care, it's also important that you find people that will care about you whether this is on your floor, clinic, even in your nurse educators, and your fellow residents. They're the people who will understand exactly what you're going through when you make those little mistakes, you have a bad day because a patient yelled at you, or those hard days. You are not alone.
Skills acquisition was also noted in these letters beyond practice in the residency skills laboratory. One resident stressed to "Perfect your assessment-having keen assessment skills and establishing a good baseline assessment for you patient is key! If there are any changes with your patient, you'll know it!" Practicing assessments was emphasized, "Attempt as many IV's as possible," for example.
Material resources were linked to fine-tuning organizational skills. Examples included making agendas or calendars, creating a template of things that pertain to your floor and using the available tools such as Micromedex to help with drug compatibilities and Care Compass, a workflow tool within the electronic patient health records system for organizing patient care. "Care Compass is your best friend," noted another. One resident noted that, to help learn resources, she has "a notebook with numerous notes and phone numbers about all kinds of resources."
Advices on getting organized prior to calling a provider were offered, as well. These included having the chart of the patient open and being prepared to answer questions, having the most recent set of vitals, and having the SBAR page of the electronic record open, a hand-off communication tool designed to give a complete picture of the patient and their care.
Subtheme: Learn from mistakes
Underlying these messages for knowledge and skills acquisition were reassurances that making mistakes is a vital part of learning (n = 18). One resident wrote, "You're going to fail at something. But you are going to get up, learn from the mistake, and be even better and stronger the next time." A second resident reinforced this message, "You're going to make mistakes, mostly silly ones that you have to laugh at yourself for. But the real struggle is when you make your first uh oh that could have been a reaaally bad mistake. You will learn from it. And do not beat yourself up for it. Again, Learn from it!!" Another resident shared her experience. "One night I spiked a tube feed bag that had a hole it and was rained down upon, including my hair. We still laugh about it every time I grab a tube feed bag, and you'd better believe I inspect it for a hole."
Theme 2: Emotions of the Profession
The nurse residents expressed numerous emotions, both negative and positive, in their letters to future nurse residents (n = 21). "Being a nurse can be very emotional," which is "normal, and eventually gets better." The emotions identified by graduating nurse residents were dynamic and often opposite one another. "You will go through a rollercoaster ride of feelings" wrote two graduates. Days will be good and bad or easy and hard. For example, "Nursing can be an all-encompassing career with many ups and downs." The three most commonly identified emotions were fear or being scared, sadness, and laughter.
Fear and feeling scared or terrified were clearly articulated by nurses graduating from the nurse residency program but with acknowledgment that it is "OK" to be scared. However, these negative fears are overcome over time. For example, one nurse resident noted that, as the nurse resident got more comfortable with cardiac arrest situations, "instead of fear you may get an adrenalin rush."
Sadness seems inevitable in being a nurse at the bedside, as suggested by the nurse residents. Along with sadness comes tears, and it is all right to cry. "I have learned not to dwell on the sadness, to know it's OK to shed a few tears, and then carry on with my day."
New nurse residents were reminded by those soon to be graduating from the program to laugh. Sometimes you laugh at yourself and other times, with others. "You are going to make mistakes, mostly silly ones that you have to laugh at yourself for." Another nurse resident wrote, "Before you know it you will be off orientation and laughing with your fellow nurse residents about how nervous you all were your first shift."
Other less frequently articulated emotions included feeling overwhelmed, intimidated, joy, and having a sense of reward or accomplishment. Nurse residents are expected to feel overwhelmed, and it is all right to feel this way. As one nurse resident wrote, "suddenly attaining so much responsibility can be overwhelming, and that's OK." Feeling intimidated was expected, especially on the first day, but it could also be experienced when talking with physicians. Nurse residents were reminded to feel joy and enjoy the chosen career and life, in general. "Do not forget to enjoy it," as one nurse resident wrote. Sometimes enjoyment comes from little successes. It may take reflection though as it was suggested to "take time each week for yourself to reflect on the hard work you are doing and celebrate it with something you enjoy."
Theme 3: The Patient/Family and Nurse Connection
Nearly half (n = 14) of the nurse residents spoke to a connectedness to patients and their families. Making this connection included the subthemes of being rewarding, requiring empathy, role of advocacy, and individualized patient- and family-centered goals.
Subtheme: Rewards
Connecting with patients and families is rewarding but hard, too. Nurses expressed the "difference" they felt they made in peoples' lives and the impact of their care among persons who depend on nurses for their health. It was the "little" things that made them feel good about being a nurse, such as when "someone gives you a weak smile or holds your hand, and may say, 'thank you, you are so special.'" A smile is something simple that is a two-way street. "Greet your patients with a smile (to brighten someone's day)[horizontal ellipsis]the smile they give back will make your day." This smile may "radiate love, fear, and hope[horizontal ellipsis]which motivate you to better yourself every day." In addition, it was rewarding to see a patient walk out of the hospital.
Subtheme: Empathy
You cannot connect with patients and families without empathy. Empathy is depicted as remembering the healthcare situation the patient and their family find themselves and being present with them. "Never be ashamed for taking time with your patients," reminded the new nurse residents. This situation may be the worst possible for both the patient and their family, filled with a potentially deadly diagnosis and challenging treatment. If "you put yourself in your patient's shoes," you will think about them, appreciate their situation, and, subsequently, "the care you provide will be enhanced" and they might "become your friends and should be respected and treated like family."
Subtheme: Advocacy
Connecting with patients and families is hard work due to responsibility. "The responsibility can be overwhelming." This responsibility centers around advocacy. "You are their voice," as well as their "mind, soul, heart, and body." When you advocate, you "stand up for your patients."
Subtheme: Patient- and family-centered goals
Nurses take care of patients, which reflects a core value of stewardship, according to one nurse in the residency program. Care is about them, the patients. The goal is to provide the best possible care and individualize care because "every patient is so different and will need a different type of care."
Theme 4: Self-Care
The fourth theme described by the nurse residents (n = 10) was self-care. Practicing healthy behaviors to counter physical and emotional stress in order to maintain well-being is known as self-care (Richards et al., 2014). Balancing self-care practices was encouraged outside work and at work.
Subtheme: Outside the work environment
Participants described self-care practices outside the work environment (n = 8). Many described the importance of not taking work home. "Leave it at work; whatever 'it' might be to you. Be it emotional, physical (floor phone), or mental. Work/home life balance NEEDS to be separate." In strong agreement, another resident believed bringing work home could "hurt you in the long run." Others expressed the importance of getting adequate rest. "Sleep. After your shift, learn to unwind, turn off your brain and rest!" Physical activity, reading, and spending time with loved ones were also noted as important self-care activities. "Do things for yourself, whether that's reading a book or going to the gym or maybe just spending time with family and friends."
Subtheme: Work environment
Participants described self-care while in the work environment (n = 7) by expressing the importance of tending to basic human needs. "Do not forget to drink water and go to the bathroom-seriously." Practicing mindfulness can help alleviate mental stress (Richards et al., 2014). Some nurse residents encouraged slowing down, taking a deep breath, and allowing one's self to feel. "Be mindful of the moments you are stepping into. Pinnacle moments of people's lives that you have one of the greatest impacts on." Ultimately, "caring for yourself will in return help you care for others and become a better nurse."
DISCUSSION
Thirty randomly selected nurse residents' legacy letters were qualitatively analyzed. Four themes with nine subthemes were identified. Knowledge and skills acquisition, emotions of the profession, the patient/family and nurse connection, and self-care were similar to themes found in other studies.
Acknowledging permission to ask questions without fear was a theme identify by Fowler et al. (2018), as well. Asking questions is part of clinical inquiry and the journey of development of critical thinking. This process is part of role development of a competent nurse (Linder, 2009). The nurse residents were reflecting and recognizing the value of knowledge and skills as a professional registered nurse (Miraglia & Asselin, 2015).
Resources included individuals that nurse residents could "go to" for a variety of support, including understanding, advice, and skill building. These individuals are members of the team, including preceptors (Wildermuth et al., 2020), and stress the importance of teamwork (Fowler et al., 2018).
Miraglia and Asselin (2015) suggested that reflection affords the opportunity to explore feelings, which was clearly evident in the array of both negative and positive emotions expressed by the nurse residents in their letters. Negative emotions such as fear, sadness, and feelings of being overwhelmed and intimidated were almost equally balanced with emotions around laughter, joy, and reward. Positive emotions were also noted in a recent "deep dive" in nurse residents' description of the art of nursing (Fowler et al., 2021). Feeling overwhelmed did not surface as a major theme in a recent study with nursing students and new graduate nurses (Wildermuth et al., 2020), but the logistics of the residency program and hospital setting may be influencing factors. This counterbalance of emotions may speak to the resilience of new graduates who have just completed an arduous nursing education only to transition to another challenging phase of their career.
Fowler et al. (2018) had identified gratitude related to patients, families, and team members in stories of graduating nurse residents, which echoed with the sense of reward that comes from connecting with others communicated by nurse residents in their letters to future nurse residents. A new nurse may feel rewarded in becoming skilled in physical tasks as such inserting peripheral intravenous catheters, but the heartfelt rewards come from relationships with patients and families. Perhaps, this connection coupled with emotions attests to the uniqueness of the profession that was also identified by Linder (2009) in her study of the lived experience of new graduate nurses.
In addition, Miraglia and Asselin (2015) suggested that reflection affords the opportunity to explore beliefs. Nurse residents shared the belief that you cannot connect with patients and families without empathy, which may be a key element in the art of nursing (Fowler et al., 2021). Individuals can reflect on assumptions, as well (Miraglia & Asselin, 2015). An assumption is accepted as true without proof (Gray et al., 2017). Three assumptions articulated in the letters were as follows: it is OK to ask questions, there are always resources, and take care of yourself.
Self-care is both an assumption and value delineated by the writings in the legacy letters. It is also part of personal development described by other new nurse graduates (Linder, 2009). Nurses are people with both professional and personal dimensions in which both need to be strong for successful transition to a professional registered nurse. Perhaps graduating nurse residents recognized that, to be resilient in the profession, you need to address holistic health, which includes yourself as a nurse and a person. These insights and subsequent behaviors, if incorporated into one's lifestyle, may impact burnout and retention.
Limitations
This study is not without limitations. Data collection occurred at one comprehensive cancer center in the southeastern United States. Thus, findings cannot be generalizable to other specialties or settings. Demographic characteristics of the participants, such as gender, were not obtained, and associations with themes were not possible. Although letters were blinded and selected by a random generator, determination of subspecialty or setting for comparisons between inpatient and outpatient nurse residents' letters cannot be made. The written legacy letters were intentionally brief and focused (i.e., "what I wish I knew" or "what I learned"), limiting the interpretation of findings. The addition of in-depth interviews may allow for a richer understanding of the experiences of oncology nurse residents completing the program.
Implications for Nursing Practice and Research
Understanding the experiences of oncology nurse residents at the end of their year-long residency can provide guidance for nurses in professional development on implementing changes to the program. Based on findings, the residency program facilitator is incorporating a session with a social worker on emotions and self-care for future cohorts. Another consideration includes inviting former nurse residents, who have been practicing a couple years beyond the program, to speak on their experiences connecting with patients and families and their journey away from the novice nurse role.
Future research may include exploring the impact on nurse residents reading the legacy letters. One consideration is to ask nurse residents to label or title their letters with one main take-home point and group letters by theme. This can allow for an examination on frequency of access for further exploration on meaningfulness. Prior to accessing, requiring staff to select their role, for example, nurse resident, nursing leadership, or nursing peer, can help determine readership. Lastly, these letters were written prior to the global COVID-19 pandemic. Restrictions including some residency days moving to virtual format were put into place. Evaluating letters during the pandemic to prior letters can help determine if new themes arose or experiences were influenced by the pandemic and further guide nursing professional development practitioners in curriculum development and enhancement of the current nurse residency program.
CONCLUSION
The purpose of legacy letters for the oncology nurse residents is to provide an opportunity for reflection and subsequent personal and professional growth and, as designed, potentially ease the transition for future nurse residents entering the program. Major themes identified can generate new knowledge about the experience in a year-long residency program and provide a guide for nurse educators in professional development in addressing and incorporating these themes into curriculum. Future research may focus on how these legacy letters are used by nurse residents during their year-long program.
References