“I had fear when I was coming in; I am confident now”: Transition experiences of newly qualified nurses and midwives in Uganda

Abstract

Introduction

Transitioning from university-based education to clinical practice may be quite challenging for newly qualified nurses and midwives. The study explored clinical transition experiences of newly qualified nursing and midwifery graduates in Uganda.

Methods

The qualitative descriptive design was used based on the Duchscher’s transition shock theory. We conducted 15 in-depth interviews among new graduates who were working in various private and public health facilities in Uganda. The data were analysed using a deductive thematic approach.

Results

We identified three themes: (1) transition experience, (2) recovery and adaptation to new roles (3) confidence and challenges during transition. New graduates’ excitement of joining clinical practice was replaced with a transition shock experience. The shock experience involved emotional and socio-cultural responses to the realities of clinical practice. Transition shock was related to unfamiliar clinical settings, fears of fitting in, fears of making mistakes, difficulty translating theory to practice and unpreparedness for clinical practice. Transition programs, including internship, orientation, training opportunities, preceptorship, and mentorship helped new graduates to adapt to new clinical settings. While new graduates were initially bereft of confidence, they eventually gained confidence and competence. During the transition phase, new graduates faced several challenges in clinical practice. These included employment challenges, poor work conditions, mistreatment, inadequate supervision and mentorship, and unrealistic expectations.

Conclusion

Newly qualified nurses and midwives experience transition shock and several challenges during the transition to clinical practice. Improving new graduates’ work conditions, support systems, supervision, and mentorship is critical in promoting positive transition experiences. Ultimately, this may help improve new graduates’ experiences during the critical transition period.

Clinical trial registration

Not applicable.

Introduction

The transition phase describes a process of learning in which newly qualified nurses and midwives, referred to herein as new graduates, adjust and transition from university-based education to professional practice [1]. Although the transition period varies across settings, it takes one to three years to acquire clinical competency [1, 2]. During transition, new graduates may be unfamiliar with clinical settings resulting in what Kramer described as reality shock when they entered into clinical practice [1]. Reality shock involves emotional responses such as feelings of anxiety, fear, stress, self-doubt, rejection, and lack of confidence [1]. Duchscher describes this experience as transition shock [3]. This is where new graduates may feel emotionally drained, and physical exhausted, and may have intellectual (e.g. difficulty translating theory to practice) and sociocultural inadequacies (e.g. difficulty being part of the team) [4, 5].

New graduates experience challenges transitioning to clinical practice. These include difficulty in adapting to new nursing roles because of their limited clinical experience, theory-practice gap, and unpreparedness to practice [6]. Amidst crises of confidence, staff shortages, and heavy workload, new graduates often have insufficient support and mentorship to enable them settle during the transition phase [7, 8]. The horizontal violence and mistreatment of new graduates in the form of bullying, belittling, and verbal abuse further pose challenges for graduates [7, 9]. The high expectations for graduate nurses and midwives alongside failure to understand their needs results in overwhelming work for them, while unmet expectations may further breed interpersonal conflicts [10].

The transition period represents a critical phase where new graduates often leave nursing practice [11]. In Turkey, 42% of new graduates thought about leaving the profession after one year [12], while 37 to 57% of new graduates in Canada wanted to leave nursing after two years in clinical practice [11]. In low- and middle-income countries, 64% of final year nursing students intended to migrate to other countries especially the United States, the United Kingdom, Australia, and Canada [13]. The significant proportion of new graduates with high attrition rates and brain drain intentions may compound the already existing shortages in the healthcare workforce [13, 14]. The shortage of healthcare workforce is disproportionately higher in sub-Saharan Africa [14]. This includes Uganda where the nurse/midwife to patient ratio is below the World Health Organization recommendations [15]. While nursing forms the majority of the healthcare workforce in Uganda, few nurses/midwives have degree qualifications [16].

The high proportion of new graduates who want to leave the profession is partly attributed to the mismanagement of the transition period [17]. Understanding the transition experience of new graduates may help in the formulation of strategies to improve their transition experience. However, the majority of literature on transition experience is limited to high-income countries particularly Australia and the United States [18]. Transition programs varies across settings [19]. This in addition to inadequate implementation of structured and formal transition programs in our setting indicate how new graduates in our setting may have unique experiences as they transition with limited support in this period. In Uganda, new graduates experience challenges of getting employment in mainstream public health settings [20, 21]. This is partly attributed to lack of recognition of the graduate program arising from the multiple entry points including the certificate and diploma-trained nurses which are seen to be more competent than new graduates [22]. As a result, new graduates in our setting may have unique transition challenges which underscores the need to explore their transition experiences which may be relevant to our context. The study, therefore, was conducted to explore (1) the transition experiences among new nurses and midwives, (2) the enablers and (3) the challenges they faced transitioning to professional practice in Uganda.

Methods

Theoretical framework

The Duchscher’s transition shock model guided the conceptualisation of the study [3, 23]. The transition shock theory examines the phases that new nurses experience when transitioning to clinical practice [1, 3]. The theory derives its concepts from Kramer’s shock theory, Benner’s novice to expert theory, and the Bridges transition theory [1]. The transition theory has three components that include the doing, being, and knowing phases [1]. The doing phase corresponds to the first three to four months when new nurses concentrate on learning and acquiring nursing skills [1]. The stark difference between the educational and clinical settings results in transitional shock [1]. This occurs in the form of emotional (e.g., fear, self-doubt, stress), physical (e.g., exhaustion), socio-cultural (e.g., sense of belonging, independence, work-life balance), and intellectual (e.g., recall of information) dimensions [1]. The doing phase is typified by feelings of self-doubt, lack of confidence, and self-efficacy [1]. In the subsequent fourth to eighth month, new graduates transition to the being phase [1]. In this phase, nurses become more familiar with the clinical setting [1]. Although the nurses in this phase may still experience transitional crises, they become more confident and proficient in their assigned clinical duties [1]. The novice nurses transition to the knowing phase where they are more independent, confident, and are aware of the dynamics of their work environment [1]. In the knowing phases, nurses become more familiar with the challenges in the healthcare system [1, 3]. This phase represents a shift from emotional turmoil due to individual inadequacies to transitional crises from healthcare system deficiencies [3].

Study design, setting, and sampling

This was a qualitative descriptive study [24]. The design is appropriate for directly describing perceptions and experiences, particularly in areas where limited information exists [24, 25]. The study was conducted in Uganda. In 1993, Uganda started training nurses at the degree or undergraduate level [16]. Institutions of higher learning recently started undergraduate training programs for midwives. Uganda has two entry points to nursing/midwifery graduate training [16]. These include nurses/midwives with diploma training, and students directly from secondary education [16]. The duration of training runs from two and a half years to four years for nurses/midwives with diploma qualifications [16]. The program may be implemented full-time or part-time which may cover specific days of the week. In contrast, students who are directly from an advanced level or secondary education are required to study for four years usually full-time [16]. The training involves theoretical biomedical sciences and clinical core nursing courses in the later years of the programs [16]. Upon completion of the program, the Uganda Nurses and Midwives Council requires new graduates to complete a one-year mandatory internship program before they are registered as nurses/midwives [16]. The mandatory internship program occurs in the mainstream public health settings where new graduates provide clinical care. While several universities in Uganda graduate a significant number of nurses and midwives at degree level [15], their number is still low [16]. As such, a majority of nurses/midwives have certificate and diploma qualifications [16]. Concerns have also been raised regarding the clinical competence of new graduates [20].

The study participants were newly qualified nurses and midwives at the bachelor’s degree level. The participants were graduates from public and private universities in Uganda which included Busitema University, Makerere University, Lira University, Muni University, and Bishop Stuart University. The new graduates had completed the mandatory internship program, were registered with the Uganda Nurses and Midwifery Council, and had not spent more than three years in professional practice. According to Benner, nurses require about two to three years to transition from a novice to a competent nurse [2]. While the study was based on the Duchscher’s transition shock model, we used Benner’s three-year work experience as the transition period. Graduate nurses and midwives with diplomas in nursing or midwifery before earning a bachelor’s degree were excluded from the study as they had prior clinical experience.

We used purposive sampling to select the study participants [26]. The newly qualified nurses and midwives were recruited from different public and private hospitals in the country. The prospective participants were asked preliminary questions such as the university they attended, their work, and experience before they were enrolled in the study. We selected participants based on the university they attended for maximum variation, while we purposively selected new graduates who were involved in clinical work and or those working in specialised units (e.g., intensive care units). We purposively selected newly qualified nurses and midwives who were working in hospital settings at the level of district hospitals, regional referral, and national referral hospitals. This included private facilities, private not-for-profit facilities, and public health facilities. The sample size was based on the principle of data saturation which involved data collection until no new insights were identified from the additional interviews [27]. We conducted 15 interviews with the nurses and the midwives.

Data collection methods and procedure

Data was collected from 12th October 2024 to 10th November 2024. The first author conducted individual in-depth interviews (IDI) with the participants after being trained in qualitative interviews. The interviews were conducted in English. An interview guide with open-ended questions was developed. The questions elicited diverse perspectives of participants’ experiences. Informed consent was always obtained from each participant before each interview session. Most (n = 13) of the interviews were conducted over the telephone, while only two were conducted face-to-face. The interviews were audio-recorded and lasted between 25 and 30 min on average.

The rigor of the study

The trustworthiness of the study findings is determined by credibility, dependability, transferability, and confirmability [28]. We interviewed nurses and midwives who attended different universities and were working with different institutions to ensure that our findings were credible [29]. The first author is a male and a newly qualified nurse which underlines the likely lack of social hierarchy between the participants and the interviewer. The rest of the authors are nurses and midwives with a rich contextual experience of nursing/midwifery in the country. This added to the credibility of the findings given their complete immersion, prolonged engagement, and awareness of the study setting [28]. We used multiple authors (EM, SRA, and JE) to analyse the data, and the Duchscher’s transition shock model to enhance the credibility of the study findings [28]. We have provided a detailed description of the study participants, their work experience, and the nursing/midwifery profession in our setting to enable assessment of the transferability of the study findings [28]. We have described our study methods for reproducibility, while an audit trail enhanced the dependability [28]. Peer debriefing from senior authors was used to ensure conformability, while self-awareness was used to help control any preconceived notions regarding transition experiences [30].

Data analysis

The audio recordings of the interviews were transcribed verbatim. Deductive thematic analysis was used to analyse data [31]. The analysis was based on a theoretical framework grounded on Duchscher’s transition shock model. The researchers (EM and JE) read the transcripts multiple times to become familiar with the data. EM and JE identified and grouped initial codes into potential subthemes. Themes were developed based on stages of Duchscher’s Transition Shock Model [32]. EM, SRA and JE met to review and refine the subthemes and themes. The themes were checked against the coded extracts and the entire dataset. The final step involved writing up the findings and integrating direct quotes from the participants to illustrate each theme.

Ethical consideration

Ethical approval was obtained from the Busitema University Faculty of Health Sciences Research and Ethics Committee (Reference number: BUFHS-2024-188). Written informed consent was obtained from all participants. All the participants consented to participate in the study except for those who declined because we failed to get an appropriate time for the interview with the participants. Confidentiality was maintained, while we kept the information in the recordings and transcripts anonymous. The interviewer may have known some of the participants before the interview.

Results

Description of the study participants

The participants were between 25 and 32 years of age. The new graduates were mostly nurses (n = 13), while midwives (n = 2) were also included in the study. Only five participants were employed by the government, while the remaining of the participants (n = 10) were employed in private health facilities. The participants worked in clinical settings including intensive care units (n = 6), paediatric (n = 5), and maternity/obstetric units (n = 4).

Experiences during the transition to clinical practice

We identified three themes: (1) transition experience (2) recovery and adaptation to new roles (3) challenges during transition to professional practice (Table 1).

Table 1.

Experiences during the transition to professional practice

Theoretical domain	Themes	Subthemes	Codes
Doing phase	Transition experience	Honeymoon phase	- Initial excitement -Eager for work
		Shock experience	- Encountered new things -Realities of clinical practice -Anxiety about fitting in. - Pressure to do the right things - Fear of making mistakes.
		Inadequate preparedness for clinical practice	- Limited hands-on experience
		Theory-practice gap	- Difficulty translating theory to practice
Being phase	Recovery and adaptation to new roles	Transition programs	- Internship training is useful. - Early orientation - Preceptorship and mentorship. - Training opportunities
		Supportive work environment	- Working with supportive workmates - Favourable work policies
Knowing phase	Confidence and challenges during transition.	Employment challenges	- Unemployment -Difficulty getting employment - Mistrust for bachelor-trained nurses - Lack of scope of practice - Perceived as expensive
		Poor work conditions	- Heavy workload - Low pay - Mental health struggles from the working conditions
		Mistreatment and inadequate mentorship	- Poor supervision and mentorship - Bullying and mistreatment - Negative criticism and feedback
		Unrealistic expectations	- Expected to know everything - Expected to be different from diploma/certificate nurses - Lack of practical skills
		Confidence in clinical practice	- Gained experience, knowledge and skills - Interpersonal skills - Feeling competent -Self-awareness - Integration into healthcare

Theme 1: transition experience

Subtheme 1.1: The honeymoon phase

During the honeymoon phase, the transition from university to professional practice brought a range of emotions. In this phase, newly graduated nurses and midwives were excited about completing school and were eager to enter into practice with love and enthusiasm.

“I was excited that after all that campus hustle and the internship hustle, I’m finally becoming a qualified professional. So, there was that bit of excitement that, ah, it’s done finally.” (IDI 14, Male nurse).

“When we had just qualified, I was so eager to reach the hospital, you know?….I was just eager to start work in a white uniform” (IDI 13, Female nurse).

Subtheme 1.2: Shock experience

The initial excitement, in the honeymoon phase, was quickly replaced with a transition shock experience. The shock experience reflected the transition phase when newly qualified nurses and midwives interfaced with the realities of clinical practice. New graduates noted that this period had an emotional toll on many of them. Many of them recalled being in a state of anxiety, fear, uncertainty, and pressure. Some experienced burnout during this phase. The graduates described this period as a difficult one for them.

My initial feelings,…it was a state of ambivalence… you are excited that you are entering the field, but you also have fear that you are…transitioning into another phase of your life…. How am I going to blend with this environment? Is it going to be welcoming? Is it going to be hard? (IDI 1, Male nurse)

“The experience actually, I can say it is not easy… you are always on pressure. Am I going to do the right thing? You are always asking questions…they give you a drug, you have never given it”(IDI 2, Male nurse).

Besides the emotional toll, the transition phase affected the social-cultural aspects of new graduates. In the early stages, graduates struggled to balance the demands of work and social life. Some became so absorbed in nursing care that they neglected their well-being. Consequently, new graduates could not socialise and have time for friends and family.

“So, maybe the only problem is that adjusting into the working hours, at times. Like, I could end up being overtaken by work that I don’t have time for myself.” (IDI 3, Female Midwife).

The shock experience was exacerbated by the new clinical environment. The clinical setting required graduates to meet different people, and to demonstrate competence using new equipment and to perform unfamiliar procedures to which they were not exposed during training. New graduates were anxious about fitting into this new clinical environment. The high expectations for the new graduates amidst crises of confidence and inexperience left no room for mistakes. Graduates had performance anxiety, especially in first-time procedures. New graduates were preoccupied with whether they were doing the right thing and were fearful of making mistakes. New graduates experienced psychological trauma because of the increased responsibility and the poor patient outcomes.

" My first night shift, I lost a patient. It was a very hard experience… So that burnout, it really haunted me so much….So, that had an emotional toll on me. " (IDI 1, Male nurse).

Subtheme 1.3: Inadequate preparedness for clinical practice

Although new nurses and midwives felt that education programs at their respective universities equipped and prepared them for clinical practice, they perceived certain gaps in their training. Graduates recalled how they encountered instruments or were required to perform certain procedures for the first time. Many newly graduated nurses reported feeling unprepared for various practical aspects of their job, particularly when dealing with specialized equipment or performing certain procedures. Unpreparedness for clinical practice was related to limited exposure to hands-on practice during their training. This heightened their dependence on senior staff and resulted in feelings of uncertainty, abuse, and limited opportunities for hands-on experience.

“My senior…. told me to prepare what to use for intubation. You think I knew what to prepare for intubation? I never knew. Most of the things I didn’t know….” (IDI 2, Male Nurse).

“So, the chance you get at school to put an IUD [intrauterine device] is actually maybe twice… So, you go to a clinic, and then… the staff gets biased and says no for you, you have bachelors… But you just first observe and then you can do after” (IDI 4, Female Nurse).

Subtheme 1.4: Theory-practice gaps

Nurses and midwives faced difficulty translating theoretical knowledge into practice. This made them frequently ask questions on how to care for patients which made them helpless, a target for harassment, and appear incompetent.

“You can have the knowledge in mind, but putting it into practice is a problem… because there are times, like, you really feel you know it, but you can’t apply it, so you have to go down and ask " (IDI 3, Female midwife).

The theory-practice gaps also reflected the gaps between what new nurses and midwives learned in class and what they encountered in real-world practice. Many expressed disappointments at the breach of standards in healthcare settings. Some participants were surprised by the unexpected practices and substandard care. This deviation from standard practices was particularly noticeable during internships, especially among senior nurses.

“You were maybe taught the ideal way of doing things at school, but when you get to the hospital, things are different… what you learned may not rhyme with what is done on the ground” (IDI 4, female nurse).

Theme 2.0: Recovery and adaptation to new roles

As new graduates gained experience, they began to adapt and develop confidence in their roles. This recovery phase was facilitated by the transitional programs, and supportive work environments.

Subtheme 2.1: Transition programs

In Uganda, new graduates spend one-year mandatory internship program in hospital settings before they qualify as nurses or midwives. This hospital-based internship program was seen to be helpful to new graduates to interface with clinical practice. Some of the private and specialised units subjected new graduates to structured orientation programs for a specified period to enable a smooth transition into professional practice. These transition programs provided them with gradual exposure to the hospital environment, time to gain clinical competence, enabled them to adjust, and it offered some form of specialized training. Participants emphasized that the transition programs improved their confidence, enabled them to understand their employer’s expectations, and reduced the overwhelming transition shock during the early days of clinical practice.

“I appreciate internship. Internship helps you, like, to develop your competence into these practical aspects in the field. Like, without internship, you will never transition from being a student to someone who has qualified, it is impossible.” (IDI 3, Female midwife).

Participants also highlighted preceptorship which they categorised as shadowing. Shadowing entailed assigning novice nurses to senior nurses after orientation. Attaching senior nurses ensured that new graduates properly understood the system and the workflow. Furthermore, new graduates were assigned to work day duties where it was possible to supervise them. New graduates recounted that identifying a mentor who was supportive helped them to learn, cope, and adapt to the new settings.

“We termed it as shadowing…. like from orientation, you would go to ward, but then to the preceptor and you work with that person… it’s like you’re working under someone, but you’re not yet fully responsible for the patients.” (IDI 7, Female nurse).

During the transition period, new graduates were exposed to training programs such as continuous professional development and specialized training. These training sessions were seen as vital tools for continuous learning, helping newly qualified nurses and midwives to bridge the gap between theoretical knowledge and practical application in patient care. By providing access to continuous professional development opportunities, hospitals ensured that new graduates remained up-to-date with the latest medical practices and felt more equipped to meet the demands of their work. Structured opportunities and specialized courses, were instrumental in helping them grow in their roles, enhance their clinical abilities, and contribute meaningfully to patient care.

“When we came, ….we were trained for three months before touching the patient….We were taught…what is expected of us. We were also given highly specialized courses to enable us acclimatize the new working environment…. So, we were gelled in gradually” (IDI 1, Male nurse).

Subtheme 2.2: Supportive work environment

Participants who worked in supportive environments expressed being more secure and comfortable in their roles. The presence of encouraging colleagues and supervisors provided much-needed emotional and practical support, especially during stressful or challenging times. This atmosphere of teamwork and constructive feedback was important in boosting new graduates’ confidence and resilience in the face of difficulties.

“Working with supportive colleagues who give you a shoulder to lean on when things are hard has helped me through the tough days… The workplace members were supportive when things were hard. They helped me cope.” (IDI 15, Female midwife).

Theme 3.0: Challenges in clinical practice

The major challenges that the new graduates faced were related to employment, poor work conditions, mistreatment and inaquate mentorship and unrealistic expectations.

Sub-theme 3.1: Challenges getting employment

New graduates expected to get employed in a well-paying setting immediately after qualifying. However, after completing the mandatory one-year internship program, several graduates struggled to get employed in mainstream public health facilities. This was partly related to preference to employ nurses/midwives at diploma and certificate levels of training. Graduate nurses were also seen to be inexperienced, overqualified, and incompetent in clinical practice compared to those with diplomas and certificates. In some cases, there was hesitancy to employ graduate nurses as they were considered as a threat to nurses with lower qualifications. In this setting, the scope of practice was not adequately implemented which meant that nursing care was the same for all nurses irrespective of their qualifications. As a result, employers opted for nurses and midwives with lower qualifications which were considered to be cheaper to employ.

“It was quite hard for me to get formal employment…. They think people at bachelors’ level are too experienced…they will threaten their positions” (IDI 4, Female nurse).

“Most of the time getting a job is very hard….For us, bachelor’s people, they don’t trust us so much with practice….they think that we’re going to ask for a lot of money… [yet] we are still providing the same services as diploma and certificate”(IDI 2, Male Nurse).

Subtheme 3.2: Poor work conditions

Most of the nurses and midwives were employed mostly in private health facilities and occasionally in private not-for-profit health facilities. This helped to retain them in clinical practice. However, some of the new graduates were employed in non-governmental organisations where the work may have not been purely clinical. Employment in private practice was characterised by heavy workloads, long working shifts, and high work demands amidst poor remuneration.

“Private practice…is difficult. Some people don’t pay. Even the little they have to pay; they go ahead and not pay. Yet, you work long hours. I remember I would work from eight to eight for six days a week.” (IDI 11, Male nurse).

Participants reported that the overwhelming workload significantly impacted their work-life balance. Many found it difficult to manage long hours often extending beyond the expected shift times. Some of the new graduates suffered from depression and stress. These were attributed to failure to acquire employment and the difficulty in sustaining their livelihood. Failing to get employment was considered stigmatising because nursing/midwifery was traditionally considered a prestigious profession with numerous employment opportunities. Some considered leaving clinical practice because of the frustration of unemployment and poor remuneration.

“It is not automatic to get a permanent job…It’s something that is really very hard and it has brought a lot of depression…There was a period…I didn’t have what to do…It was.…a very depressing moment” (IDI 3, Female midwife).

“Psychologically, I was a bit tortured because when I was just from school, I expected to get this big job and big employed” (IDI 4, Female Nurse).

Subtheme 3.3: Mistreatment and inadequate mentorship

Many participants reported a lack of adequate mentorship and guidance, which hindered their smooth transition from the university to professional practice. Newly qualified nurses and midwives felt unsupported and unwelcome to the profession. The lack of support and welcome were mostly during internships and early days at their jobs. They highlighted that it seemed like the senior nurses and midwives were waiting for the new nurses to make mistakes and criticise them for it. In some cases, senior nurses were reported to be unhelpful, dismissive, or even hostile towards new graduates. This behaviour included undermining new graduates, and making them feel incapable or inadequate. They attributed these challenges to the bad attitude of senior staff nurses. The lack of constructive feedback and the dismissive attitudes of senior staff made it challenging for new graduates to gain confidence in their new roles. The harsh feedback also exacerbated feelings of anxiety and self-doubt during the transition shock period. New nurses felt discouraged from continuing as nurses/midwives as some harboured intentions to leave their roles.

“We are under looked by those people who have been so long in practice. So, they consider themselves to know a lot of things and…. then they say, you know the theory, you don’t know the practical” (IDI 2, Male nurse).

The abuse, mistreatment, and lack of support made novice nurses/midwives fear consulting the senior nurses regarding patient care. Subsequently, novice nurses/midwives felt isolated which could have led to fatal mistakes. The unfavourable attitude of senior nurses affected the new graduate nurses’ and midwives’ confidence in seeking guidance:

“Sometimes you fear asking too many questions because they start thinking you don’t know anything…… It’s like you’re on your own.” (IDI 5, Male nurse).

Subtheme 3.4: Unrealistic expectations

New graduates struggled with the high expectations placed on them in clinical practice. New graduates were expected to be more knowledgeable and more competent than nurses/midwives of lower qualifications. This occurred despite their limited learning opportunities while in school and their inadequate clinical experience. While new graduates struggled with high expectations, they also had difficulty with concerns regarding their clinical competence.

“People have high expectations from us. Like, you bachelor nurses, how different are you from the diploma nurses and the certificate nurses” (IDI 14, Male nurse).

“People think this is someone who’s very fresh, they don’t know anything, like, in the practical areas” (IDI 4, Female nurse).

Subtheme 3.5: Confidence in clinical practice

Initially, new graduates joined the clinical practice when they were fearful and bereft of confidence. During the transition period, however, they gained clinical experience which boosted their confidence, skills, and competence in clinical practice. The graduates were knowledgeable of their distinct professional roles in the healthcare team, their expectations, and the interpersonal skills needed to work with others, The graduates noted that they were proficient in nursing care with minimal supervision, while they were more independent and were fully integrated in the provision of healthcare. This led to a sense of fulfilment and growth.

“I have grown psychologically…I’m able to reason out things better than I used to…Right now, I know how the system works…I know my distinct roles, I know what I’m supposed to, I know what is expected of me.” (IDI 14, Male Nurse).

“I’m a better nurse and I am much more confident in the way I do my nursing practice because I have been boosted with a lot of knowledge and I’ve also built experience. I had fear when I was coming in; I am confident now.” (IDI 1, Male Nurse).

Discussion

The study was conducted to understand the clinical transition experiences among newly graduated nurses and midwives in Uganda. Newly qualified nurses’ and midwives’ initial excitement was punctuated with fear and anxiety in the early phases of transition. Our study findings were consistent with the other studies that noted ambivalent feelings of excitement and stress among new graduates during the transition period [4, 33]. These mixed feelings during the initial phases of transition align with Kramer’s and Duchscher’s observations of excitement in the honeymoon phase and subsequent experiences of transition shock [3]. In our study, new graduates were unsettled in the initial transition period because of the unfamiliar clinical environment, the pressure to fit in and have a sense of belonging, and the fear of making mistakes. The heightened negative emotions among new graduates underscore the importance of orientation programs, preceptorships, mentorships, and support systems to facilitate a smooth transition to clinical practice [9].

Nursing and midwifery students are often not adequately supported and mentored during their training in clinical settings [6, 34]. In our study, newly qualified nurses/midwives recounted inadequate support, mentorship, and preceptorship amidst negative criticism, bullying, and mistreatment from senior nurses and midwives. This suggests that this lack of support extended from nursing students to even new graduates [35]. This highlights a missed opportunity to mentor, and welcome young graduates into the profession. In our setting, newly qualified graduates were sometimes supervised by nurses/midwives of lower qualifications. Previous studies have observed how the disharmony in supervision resulted in mistreatment, unrealistic expectations and accusations that the bachelor-trained nurses/midwives were incompetent [8, 20]. The fear that new graduates would eventually come after their jobs may partly explain the existing friction between the bachelor-trained graduates and nurses/midwives with lower qualifications [8]. Mistreatment and bullying of young nurses and midwives correspond to the horizontal violence common in the nursing profession [8]. Considering the enormous needs for support among young nurses/midwives during the early stages of their careers, mistreatment may result in mistrust, hesitancy to ask for help and tendencies to conceal their shortcomings [3]. Mistrust and concealment may predispose to medical errors and high attrition rates [3, 12]. Addressing the social support system during this critical phase may play a role in the retention of graduates in the nursing profession and also inculcate a positive collegial environment.

Previous studies have cited a lack of preparedness and readiness for clinical practice among new nursing/midwifery graduates [1, 33]. Graduates, in our study, recounted performing procedures for the first time, which often heightened their performance anxiety. In our setting, students had limited clinical exposure which left them unprepared for clinical practice. Ultimately, theory-practice gaps and unpreparedness for clinical practice among new graduates reflects gaps in clinical training [36]. Consequently, in our study, perceived unreadiness to practice meant that new graduates were restricted to first observing clinical procedures which further limited their opportunities to gain hands-on practice. Consequently, this may affect their ability to acquire clinical skills in the initial phases of transition. Simulation could be used to help bridge gaps in training through providing students with avenues for hands-on practice experience to adequately prepare new graduates for the realities of clinical practice [37].

Nursing and midwifery graduates, in our study, struggled to get employed in the early phases of their careers. In Uganda, the reluctance to employ graduate nurses and midwives in the mainstream public health facilities left them to exploitation in private health facilities. This translated to meant that newly qualified nurses/midwives, in our setting, struggled with heavy workload, work-life imbalance, and poor remuneration in private facilities. Employment struggles among new graduates may be perpetrated by the notion that graduate nurses/midwives lack adequate clinical skills [8]. While new graduates, in our study, were bereft of confidence in the early transition period, they eventually gained confidence, skills and competencies. Furthermore, the perceived lack of competence contradicts evidence that underscores that employing nursing/midwifery graduates leads to better patient outcomes, critical thinking, research abilities, and leadership skills than nurses with lower qualifications [38, 39]. Amidst challenges in implementing the scope of practice, recognition of degree qualifications, and competition from lower cadre nurses/midwives hindered employment of new graduates in our study. New graduates were often stressed and depressed following employment struggles and the unconducive work environments which was consistent with other study findings [9]. Previous studies have noted where nursing graduates left clinical practice for non-clinical work and brain drain to outside countries [20, 40]. Besides the wasteful investment in training graduate nurses/midwives, the brain drain negatively affects the quality of nursing care and ultimately patient outcomes [14]. While recruitment of new graduates into public health settings has improved over time in our setting, more effort is needed to absorb newly graduated nurses into public health settings. This may help reduce the attrition rate and brain during the critical transition period.

Strengths and limitations of the study

The study explored a context that is underrepresented in nursing literature, offering a unique understanding of the transition experiences in low-resource settings like Uganda. Most interviews were held over the phone calls which could have limited the researcher from identifying the non-verbal cues. The study did not triangulate methods of data collection which may have affected the rigor of the study. The study findings are limited to newly qualified nurses and midwives. The study does not provide perspectives of senior nurses and midwives related to their experience supervising newly qualified nurses and midwives who were transitioning to clinical practice.

Conclusion

Our study findings underscore the transition experiences of new graduates. Although new graduates were initially excited to enter into practice, they experienced transition shock which was typified with emotional feelings of anxiety, uncertainty, fear and pressure to conform to realities of practice. The transition shock experience was related to unpreparedness for practice, theory-practice gaps, fear of mistakes, and realities of clinical practice. This necessitated new graduates to recover and adapt to new professional roles. Transition programs especially hospital-based internships, early orientation, training opportunities, mentorship and supervision were seen to help new graduates adapt and adjust to the new environment. While the graduates lacked confidence in the early phases, they felt confident and independent in the later phases of their careers. Graduates struggled with challenges of employment, inadequate support systems, and high expectations. Strengthening the social support system, mentorship, and transition programs is critical in improving the experience and retention of new graduates into clinical practice.

Abbreviations

CME

Continuous medical education

BUFHS

Busitema University Faculty of Health Sciences

IUD

Intrauterine device

Author contributions

E.M. and J.E. were involved in developing the idea and conceptualizing the study. E.M., M.P., R.C.N., and J.E. designed the study. E.M. conducted data collection, while E.M. and S.R.A. analysed the data. E.M. drafted the first manuscript, while M.P., R.C.N., T.A.K., S.R.A., and J.E. reviewed the manuscript. J.E. provided the overall oversight in the design and implementation of the study. All authors have read and approved the manuscript.

Funding

The study received no funding.

Data availability

Data is provided within the manuscript or supplementary information files.

Declarations

Ethical approval and consent to participate

Approval was obtained from the Busitema University Faculty of Health Sciences Research and Ethics Committee under reference number; BUFHS-2024-188. We obtained written informed consent from the participants. The study was conducted in compliance with the Helsinki Declaration.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.