Factors influencing new graduates’ transition into practice: A Literature Review
New graduate registered nurses (RNs) begin practicing as licensed RNs immediately after graduation. An unintended impact of this entry into practice is the placement of newly graduated nurses into a clinical setting that demands the quality, effective and safe provision of healthcare (Maria, Ki Stanley, & Lai Mei, 2018). The majority of healthcare practitioners in any healthcare system are nurses but, the move from school to a real-world environment is distinguished by reality shocks and high stress that result in high rates of turnovers. The process presents a challenge to the working life of nurses. Nurses require backing from their managers, peers, and families (Maria, Ki Stanley, & Lai Mei, 2018).
Wallace (2016) defines transition as the action of advancing from one situation to another, which is linked with a shift in responsibilities, roles, and goals. Different studies have identified various issues that come up during the transition, that include burnout, panic, tension, fear, and anxiety. These issues undermine and endanger the mental and physical health of nurses. This exacerbates nurse turnover rates after the first year of practice, and are then replaced by new novice staffs that have little confidence, experience, and knowledge for working in a demanding environment. A direct proportionality exists between the quality of life of nurses and care quality they provide. Thus, the ultimate consequence of ineffectively adapting to transition into practice is the provision of low-quality care and poor health outcomes for the patients (Wallace, 2016).
Effectively adapting to the anxiety and stress associated with the transition is critical nurses’ life and development as persons. Failure to address the factors that influence the ability of nurses and other healthcare workers (HCWs) to confront transition undermine their effectiveness and negatively affects their performance. Also, it leads to overdependence, denial, isolation, fear, projection, poor job motivation and job satisfaction, failure to meet professional mandates, and focus on the technical features of healthcare rather than evidence-based. Overall, it compromises various aspects of the lives of nurses and healthcare providers. Perhaps the most significant factor influencing new graduates’ transition into practice is their inadequate preparation (Hezaveh, Rafii, & Seyedfatemi, 2014). Preparation encompasses the acquisition of knowledge regarding transition incidents. It also involves the identification of appropriate approaches for managing the hardships that come with it. Unpreparedness among novice nurses while transitioning into practice may have grave consequences for not only the patient but also the nurse.
There is a need for nursing managers and educational mentors to prepare novice nurses through active orientation initiatives before commencing work and regularly revising the nursing curriculum. Thus, novice RNs that are adequately prepared easily transition whereas lack of it makes the process difficult (Hezaveh, Rafii, & Seyedfatemi, 2014). Various studies have revealed the experiences of new graduate nurses during the transition, but most of them do not offer reliable evidence. First, findings are often from a culturally different context that somehow cannot apply to western society. Secondly, the number of participants is usually small, and their responses cannot be assumed to be an accurate representation of the entire novice nurse population.
The objective of this paper is to explore the various factors that affect new graduates’ transition into practice.
An extensive search was performed on various electronic databases using a range of subject headings and keywords appropriate to multiple factors affecting new graduates’ transition into practice. The databases included Cochrane Library (cochranelibrary.com), Medline (ncbi.nlm.nih.gov), CINAHL (health.ebsco.com), Physiotherapy Evidence Database (PEDro), and PsycINFO. The search was simple, and involved the use of keywords and search statements such as “nurses’ transition into practice,” “experiences of novice nurses,” and “factors affecting nurses’ transition into practice.” The search was limited to refereed full-text journal articles related to the topic that was published not more than fifteen years ago. Alternate terms and synonyms were used to elicit further information.
The number of search retrieves from various databases was relatively high. Most of the peer-reviewed articles found were disregarded due to a variety of reasons. First, full texts were not available in the database. Secondly, findings were from culturally different contexts inapplicable to the Australian context. Thirdly, some may have had the key terms, phrases, and statements but the topics were different upon reading their abstracts. Fourthly, some were relevant but were published more than fifteen years ago.
Eight articles satisfactorily met the search criteria highlighted above, that include studies by Houghton (2014), Innes and Calleja (2018), Ortega et al. (2015), Dyess and Parker (2012), Kelly and Ahern (2009), Charleston et al. (2007), Guerrero, Chênevert, and Kilroy (2017) and Wong et al. (2018). While the majority of the studies were qualitative, a few of them were quantitative. Several factors were found to influence new graduates’ transition into practice. The factors fall under two categories; degree (or lack) of support (actual and perceived), and unpreparedness while new graduates are transitioning into practice
Lack of support
According to Dyess and Parker (2012), provision of educational support has beneficial impacts on nurses’ ability to adapt to the transition, retention in the profession and professional skills. The study by Dyess and Parker (2012) explored a continuous programme developed and implemented to support the transition into practice. The study involved quantitative data collection and analysis of one hundred and nine novice nurses that took part in the continuous programme for ten months programme. The findings showed improved skill acquisition, retention, and support during transition among participants that participated in the plan. Also, technical and psychosocial skills, as well as leadership development, was improved. The findings by Dyess and Parker (2012) affirm the significance of support during the transition, and nurse managers should put into consider implementing transition support initiatives.
The findings by Dyess and Parker (2012) echo those of Kelly and Ahern (2009). According to Kelly and Ahern (2009), a demanding clinical setting that lacks adequate support from human resource management and colleagues causes nurses to resign or change careers altogether. In their study, Kelly and Ahern (2009) utilized Husserl’s phenomenological method in a bid to understand the experiences of novice nurses. They interviewed 13 final semester nursing students in an Australian University and later in a clinical setting using semi‐structured interviews. They used thematic analysis to analyze data collected before, one month into, and six months after employment. Their findings showed novice nurses had positive expectations prior to employment but, this changed after one month as they realized that the profession was characterized by “inner circles” that excluded them.
Support also includes adequate orientations. According to Charleston et al. (2007), inadequate orientation influences transition into practice. Charleston et al. (2007) conducted a study to examine psychiatric graduate nurse programs in Victoria, Australia. The review was a thematic evaluation to analyze data from individuals from 21 area mental health services. The findings showed that effective orientation was significant in learning and gaining confidence among novice nurses. Charleston et al. (2007) concluded by highlighting the need to implement a supportive, structured and formal orientation.
Lack of welfare services poses a critical obstacle to nurses in coping with the transition (Innes & Calleja, 2018). While conducting an integrative literature review, Innes and Calleja (2018) explored the transition of new graduates into critical care. This is a field that is potentially strenuous as compared to other areas owing to the level of specialized knowledge and skills required. Innes and Calleja (2018) acknowledged that the aspects of welfare services that best support novice nurses enhance their confidence and competence while coping with transition are unknown. Dimensions identified in the study include socialization, workplace culture, designated resource personnel, skill and knowledge acquisition, rotation, and orientation.
Unpreparedness while transitioning into practice
The inefficiency of university education influences new graduates’ transition into practice. Universities inefficiently train and prepare for the transition into practice. A study by Ortega et al. (2015) was aimed at identifying the education that nurses and other HCWs receive and the applicability in the medical setting. The study took the descriptive observational approach and utilized a questionnaire aimed at inquiring the adaptation of the novice nurse to the workplace. The findings showed that 53.8 percent of nursing professionals viewed the education they received as irrelevant in a clinical setting whereas 94.2 percent of nurses admitted that a connection between education and the medical environment has significant effects on care quality. This study satisfactorily determined that nurses and other HCWs acknowledge the need for university education to be customized to conform to the requirements of the clinical setting.
New nurses are often unprepared for problems attributable to the serious shortage of nursing staff in the clinical environment. While investigating the challenges facing new graduates’ transition into practice in Hong Kong, Wong et al. (2018) conducted a qualitative study involving an individual interview of 8 novice nurses (four males and four females) from one college and later analyzed the data using thematic coding. They identified a total of nine themes that included one common attribute and eight areas of challenges. According to the study, novice nurses have a common characteristic of possession of favorable attitude toward practice. The eight problematic areas commonly encountered in the transition period include change of role, workload, lack of knowledge, working atmosphere, communication, blame culture, support, and expectation. All of these issues were determined to be exacerbated by the overwhelming problem of the shortage of nurses. Wong et al. (2018) recommended that the concerned stakeholders develop strategies that facilitated continuous improvement and support to new graduates transitioning into practice.
Preparedness can be viewed from the perspective of the nurses’ professional commitment, which is a significant factor affecting their management of issues associated with the transition. A study by Guerrero, Chênevert, and Kilroy (2017) evaluated the factors that foster professional commitment among new graduate nurses and the effects of the commitment on their physical health, anxiety, and turnover aspirations. The researcher carried out a three-wave longitudinal study, where nurses were evaluated before and twice after entry into practice. Guerrero, Chênevert, and Kilroy (2017) found that professional commitment is related to the reduction of nurses’ anxiety, and increases in their turnover aspirations.
Professional relationships, especially poor working relationships, influence new graduates’ transition into practice (Houghton, 2014). Houghton (2014) conducted a critical review of organizational socialization articles to determine how novice nurses adapt to clinical practice while highlighting approaches that potentially improve their learning experiences. The rationale behind the study by Houghton (2014) is that professional relationships facilitate learning in a clinical environment. By assessing recent studies and seminal literature on newcomer adaptation and organizational socialization, Houghton (2014) determined that an understanding of socialization skills is advantageous in creating a clinical learning setting. Particularly, role modeling was determined to be imperative in the smooth transition of novice HCWs. This, coupled with the disposition of the novice nurse, improved their transition process.
Several factors impact the transition of new graduate nurses into practice but, they all boil down to degree of support, and unpreparedness while new graduates are transitioning into practice. Communication-related issues trigger novice nurses to turn to inappropriate defensive behaviors like silence, isolation, and anger. Providers and novice nurses can influence transition into practice through robust professional relationships (Houghton, 2014). In as much as lack of welfare services, which poses a critical obstacle to nurses in coping with the transition into practice, implementing an accommodating workplace culture, assigning a quality resource personnel, providing positive socialization experiences, structured orientation and skill and knowledge acquisition that puts into perspective the novice nurses’ learning needs enhances not only their transition into practice but also their competence and confidence (Innes & Calleja, 2018). The absence of qualified mentors and preceptors may contribute to poor transition among nurses. As such, novice nurses should be provided with a mentor- and preceptor-mediated training to not only prepare them for transitions but also enhance their coping skills.
The inefficiency of university education in getting the nurses ready for the transition into practice is noteworthy (Ortega et al., 2015). Providers need to perform staff training and development since the nursing education offered in some universities not only reduces their autonomy (at least professionally) but also do not prepare them adequately for the transition to practice. Ideally, the objective of pursuing academic education is to receive training and knowledge to enable the nurse in assessment, identification, implementation, and evaluation of health needs and care for both the sick and the healthy. The extent of support (actual and perceived) is a crucial aspect of nurses’ ability to smooth transition of new graduates into practice (Dyess & Parker, 2012). Support by parents, spouses, families, and peers is imperative in providing emotional support to nurses and other HCWs. Lack of support is linked with job dissatisfaction and burnout. Team leaders should offer different types of support to assist new graduate nurses in coping with transitions. Most novice nurses are unprepared for workplace stressors and oppressive practices. Among the recommendations presented by Kelly and Ahern (2009) was the need for providers to confront stressors and oppressive practices like hostility in the workplace to reduce turnover rates.
Orientation programs are often not implemented in Australia despite the widely acknowledged benefits of orientation in facilitating a smooth transition. Insufficiently prepared nurses are incapable of smooth transitioning into practice, and the poor transition is related to poor outcomes like shortage of nursing staff due to high turnover rates (Brown & Sorrell, 2017). Providers are after staff with impeccable problem-solving skills and high commitment, intending to improve the efficiency of their services. In so doing, they should never take for granted the factors highlighted above. Providers should provide a favorable working environment and helpful resources to reduce the profession’s turnover rates during the transition to practice.
The emotional stress and initial shock encountered by new graduates transitioning into clinical practice is not a new phenomenon. This is attributable to various factors highlighted above that can fall into two categories; degree of support, and unpreparedness while new graduates are transitioning into practice. However, the extent of their influence requires further research. Also, more research is necessary to evaluate the new graduates’ transition into different clinical settings to inform workforce practices, policy, and support. There is a serious global shortage of nursing practitioners, yet the demand for their services is ever increasing. It is imperative that policymakers, nurse managers and leaders to gain insight into the factors influencing new graduates’ transition into practice transition as well as their impacts to enhance their transition experience and ensure retention.
Brown, T., & Sorrell, J. (2017). Challenges of novice nurse educator’s transition from practice to classroom. Teaching and Learning in Nursing, 12(3), 207-211. Retrieved from https://doi.org/10.1016/j.teln.2017.03.002
Charleston, R., Hayman-White, K., Ryan, R., & Happell, B. (2007). Understanding the importance of effective orientation: what does this mean in psychiatric graduate nurse programs?. Australian Journal of Advanced Nursing, The, 25(1), 24. Retrieved from http://www.ajan.com.au/Vol25/Vol25.1-3.pdf
Dyess, S., & Parker, C. G. (2012). Transition support for the newly licensed nurse: A programme that made a difference. Journal of Nursing Management, 20(5), 615-623. Retrieved from https://doi.org/10.1111/j.1365-2834.2012.01330.x
Guerrero, S., Chênevert, D., & Kilroy, S. (2017). New graduate nurses’ professional commitment: antecedents and outcomes. Journal of Nursing Scholarship, 49(5), 572-579. Retrieved from https://doi.org/10.1111/jnu.12323
Hezaveh, M. S., Rafii, F., & Seyedfatemi, N. (2014). Novice nurses’ experiences of unpreparedness at the beginning of the work. Global journal of health science, 6(1), 215. Retrieved from https://dx.doi.org/10.5539%2Fgjhs.v6n1p215
Houghton, C. E. (2014). ‘Newcomer adaptation’: a lens through which to understand how nursing students fit in with the real world of practice. Journal of clinical nursing, 23(15-16), 2367-2375. Retrieved from https://doi.org/10.1111/jocn.12451
Innes, T., & Calleja, P. (2018). Transition support for new graduate and novice nurses in critical care settings: an integrative review of the literature. Nurse education in practice, 30, 62-72. Retrieved from https://doi.org/10.1016/j.nepr.2018.03.001
Kelly, J., & Ahern, K. (2009). Preparing nurses for practice: a phenomenological study of the new graduate in Australia. Journal of Clinical Nursing, 18(6), 910-918. Retrieved from https://doi.org/10.1111/j.1365-2702.2008.02308.x
Maria, H., Ki Stanley, L., & Lai Mei, W. (2018). The transition challenges faced by new graduate nurses in their first year of professional experience. GSTF Journal Of Nursing And Health Care (JNHC), 5(1). Retrieved from http://dl6.globalstf.org/index.php/jnhc/article/view/1240
Ortega, M. D. C. B., Cecagno, D., Llor, A. M. S., Siqueira, H. C. H. D., Montesinos, M. J. L., & Soler, L. M. (2015). Academic training of nursing professionals and its relevance to the workplace. Revista latino-americana de enfermagem, 23(3), 404-410. Retrieved from https://dx.doi.org/10.1590%2F0104-1169.0432.2569
Wallace, D. R. (2016). Reflective writing: Factors that influence the successful transition of nursing students entering into their second semester of a RN-ABSN program. Journal of Nursing Education and Practice, 6(10), 43. Retrieved from http://www.sciedupress.com/journal/index.php/jnep/article/view/9118/0
Wong, S. W. J., Che, W. S. W., Cheng, M. T. C., Cheung, C. K., Cheung, T. Y. J., Lee, K. Y., So, K.C., & Yip, S. L. (2018). Challenges of fresh nursing graduates during their transition period. Journal of Nursing Education and Practice, 8(6), 30-37. Retrieved from https://doi.org/10.5430/jnep.v8n6p30
Appendix A: Table of Evidence