New Nurses’ Perceptions on Transition to Practice: A Thematic Analysis

Abstract

Background

New nurses’ transition to the workforce is often described as challenging and stressful. Concerns over this transition to practice are well documented, with the hypothesis that transition experiences influence the retention of new nurses in the workforce and profession.

Methods

In a cross-sectional survey (N = 217) to assess new nurse transition in the province of Ontario, Canada, an open-ended item was included to solicit specific examples of the transition experience. The comments underwent thematic analysis to identify the facilitators and barriers of transition to practice for new nurses.

Results

Comments were provided by 196 respondents. Three facilitator themes (supportive teams; feeling accepted, confident, and prepared; new graduate guarantee) and four barrier themes (feeling unprepared; discouraging realities and unsupportive cultures; lacking confidence/feeling unsure; false hope) to new nurse transition emerged.

Conclusions

Concerns of nursing shortages are heightened in the current COVID-19 pandemic, reinforcing the priority of retaining new nurses in the workforce. The reported themes offer insight into the contribution of a supportive work environment to new nurses’ transition. The recommendations focus on aspects of supportive environments and educational strategies, including final practicums, to assist nursing students’ development of self-efficacy and preparation for the workplace.

Concerns over new nurses’ transition to practice are well documented globally and are suggested to influence the retention of new nurses in the workforce and profession. The changes new nurses, also referred to as graduate nurses, undergo as they socialize into the profession, as well as the perceived mismatch between the professional values cultivated during their education and workplace values, were first described by Kramer (1974). Kramer coined the term reality shock, which describes the “reactions of new workers when they find themselves in a work situation for which they have spent several years preparing and for which they thought they were going to be prepared, and then suddenly find that they are not” (Kramer, 1974, p. vii). Over the past 40 years, nurse researchers have continued to study new nurses using a variety of approaches, to assess the transition experience, and to examine various other concepts related to new nurses. In our current context of a global COVID-19 pandemic, nursing shortages are likely to escalate and the challenges experienced by new nurses transitioning into the workforce may persist, and possibly worsen if not addressed.

Background & purpose

A review of the literature identified numerous concepts and constructs related to the transition of new nurses that include, but are not limited to, expectations for practice, socialization, confidence, stress, conflict, and support. Each of these factors, if present or absent, positive or negative, are suggested to influence the transition process for new nurses in the workplace. These factors tend to overlap and co-exist; for example, a workplace where the expectations placed on the new nurses are unrealistically high may also be a workplace where not enough support is provided to the new nurse. Such a workplace may be perceived as stressful for new nurses and not supportive to building confidence in their nursing practice. Supportive strategies and intervention to help transition new nurses are also noted in the literature, such as nurse residency or transition programs. Each of these factors will be discussed further below.

Expectations for practice

In Kramer's (1974) seminal research related to postgraduate nurse socialization, a stage of moral outrage is described, where the new nurse has feelings of frustration and discomfort, with the realization that the ideals taught in school are not the reality. These concerns have persisted over time, and were reported more recently by Ortiz (2016) among new nurses in New York state, reporting “how vastly different the real world of healthcare is compared to the shelter of nursing school” (p. 22).

Some researchers report instances where employers are seeking new nurses who are ready to hit the ground running to meet the urgent needs of the practice settings or they set unrealistic expectations of new nurses for which they are ill-equipped (Chernomas et al., 2010; Romyn et al., 2009). Parker et al.’s (2014) results from focus groups in Australia illustrate new nurses’ concerns of unanticipated expectations, as they reported challenges with patient loads, obligations to supervise junior staff, and feeling that employer expectation levels were unreasonable and unsafe. Similar findings between the ideal and the real were also reported in the United Kingdom (Halpin et al., 2017) and New Zealand (Hunter & Cook, 2018), where new nurses reported additional stressors related to workload, which included not having enough time to complete paperwork, and missing breaks. Not dissimilar were findings from Ireland (Suresh et al., 2013) where a theme of excessive workload emerged from the data analysis and captured the new nurses’ concerns of non-nursing tasks, dissatisfaction with low staffing levels, and not having enough time to meet the emotional needs of clients.

Socialization

In the first three to four months of practice, Duchscher (2008) reported that new nurses hide their emotions from colleagues to conceal feelings of inadequacy. At this early stage, new nurses feel the need to fit in socially with the team. Researchers from various countries have reported the need of new nurses to fit in, particularly as they desire respect and acceptance from colleagues (Andersson & Edberg, 2010; Feng & Tsai, 2012; Frögéli et al., 2019; Hunter & Cook, 2018; Malouf & West, 2011) and wish to feel like part of the team (Craig et al., 2012; Hunter & Cook, 2018). Andersson and Edberg (2010) studied the experiences of new nurses during the first 12 months of practice in Sweden, and reported that new nurses felt like “a rookie” (p. 188) in relationships with other staff and patients, and needed to be accepted by colleagues before being able to focus their energy on acceptance from patients. These new nurses recognized that as others listened to them, they felt respected, their self-confidence increased and in turn helped them grow in their professional role (Andersson & Edberg, 2010). Similarly, Ortiz (2016) reported that building relationships was an important element for new nurses to develop personal confidence, which increased over time as the relationships were built.

Confidence

In addition to issues of mis-matched expectations, workload, and relationships with colleagues described above, concerns of new nurses’ lack of confidence are numerous in the literature. Examples of lack of confidence include communicating with physicians and patients (Ortiz, 2016), delegating, setting priorities, organizing care needs, and making suggestions to the plan of care (Casey et al., 2004). Investigators have verified that confidence among new nurses increases with experience (Andersson & Edberg, 2010; Kumaran & Carney, 2014; Ortiz, 2016). Furthermore, confidence is an indicator of successful transition (Craig et al., 2012) and is associated with lower burnout (Frögéli et al., 2019).

Parker et al. (2014) found new nurses to be flexible and adaptive to new circumstances and varying expectations, with their confidence growing over time as they gained skills and an understanding of the workplace culture. Likewise, from a survey of new nurses (N = 83) in the state of Oregon, Craig et al. (2012), reported that the respondents had realistic expectations of practice, and that they put in additional time for study and preparation outside of work to gain confidence. Hence, being self-directed in gaining knowledge needed for practice contributed to these new nurses’ successful transition. This offers a unique perspective on how new nurses may increase confidence, separate from time in the role and gaining experience in practice.

Stress

Lacking confidence needed for some situations are among the stressors faced by new nurses (Duchscher, 2008; Kumaran & Carney, 2014; Patterson et al., 2013) and influences their decision to stay in their positions (Patterson et al., 2013). Identified stressors of new nurses in the United Kingdom (N = 282) included death and dying, conflict with physicians, inadequate preparation, lack of support, conflict with nurses, workload and uncertainty concerning treatment (Halpin et al., 2017). Measuring stress at three consecutive times in the first year of practice, the authors found that the aforementioned sources of stress occurred at all data collection points, with workload the most frequently reported stressor at each time interval. These findings align with results that emerged in an integrative review of 21 studies from several countries that investigated job stress in new nurses as they transition to practice (Labrague & McEnroe-Petitte, 2018). The key findings of the review were that new nurses: experience low to moderate levels of stress during their initial employment as a nurse; report heavy workloads as a main stressor; and, lack professional nursing competence.

Conflict

Colleagues and others in the work environment also influence new nurses’ transition. New nurses have reported challenges with communicating and collaborating with physicians (Ortiz, 2016) and have experienced bullying and harassment by co-workers (Rush et al., 2014). Focusing on nurse-to-nurse relationships, the term horizontal violence is commonly noted in the literature related to the experiences of new nurses. Horizontal violence was a key finding from a qualitative study (N = 81) that examined new nurses’ experiences in Florida (Dyess & Sherman, 2009). The nurses experienced unsupportive and unkind nurses in their practice. More recently, workplace incivility has been reported as a problem for new nurses (Halpin et al., 2017; Laschinger et al., 2016). Incivility towards new nurses from managers, colleagues and support workers was identified as major stressor by Halpin et al., Yet, some participants reported that stress and fears diminished when they experienced support from a “good team” (p. 2583), and being part of a good team was rationale for staying in a job.

Support

Workplaces have implemented strategies to provide support to new nurses, most notably residency and transition programs in an effort to improve new nurses’ transition to, and retention in, the workforce. In a systematic review of 30 quantitative studies designed to examine the effectiveness of transition strategies and interventions, 14 investigations focused on nurse internship/residency programs (Edward et al., 2015). The authors identified that these nurse internship/residency programs had common elements of “taught days” (p. 1262) and additional clinical support for new nurses. Outcomes of the programs were categorized as those important to employers, such as retention and turnover rates, or individual nurse outcomes, including confidence, competence, knowledge, stress, anxiety and job satisfaction. Edwards et al. (2015) concluded that the poor methodological quality of the studies prohibited determining the effectiveness of strategies, yet they suggested that transition programs may be generally useful in increasing retention and improving new nurses’ overall experience.

Within Canada, the Ontario provincial government launched a strategy for new nurses in 2007 called the Nursing Graduate Guarantee (NGG). The NGG currently offers full-time, mentored support, where new nurses work in supernumerary positions (i.e., above staffing complement) with the aim to secure permanent full-time positions in the organization. A survey of new Ontario nursing graduates between 2007 and 2012 evaluated the policy and compare employment status, retention and perception of clinical proficiency between NGG participants and non-NGG participants (Bauman et al., 2018). A significantly higher portion of the 1375 Registered Nurses (RNs) who had participated in the NGG reported full-time employment status (63%) compared to their counterparts (56%) (Baumann et al., 2018). For those graduated between 2009 and 2012, a higher proportion of RNs who participated in the NGG remained with the same employer as their initial position (73% compared to 59% of the non-NGG participants), and perceived a higher level of clinical competency on scale items rated. These results suggest that full-time employment for new nurses offered by the NGG may improve retention of new nurses by an employer, and support new nurses’ perception of their clinical proficiency. Although Baumann et al., report that 43% of Ontario's new nurses were hired into NGG positions between 2007 and 2012, an inventory of what other currently offered interventions exist within Ontario to support new nurse transitions, either as institutional supports or transition-type programs, was not found by the authors.

At the time of this study, Ontario's new nurses’ perspective of transition facilitators and barriers was not found in the literature. Given Ontario's unique policy described previously, a better understanding of their perspective is warranted.

Aim

Our study was undertaken to test a model linking the constructs of transition and intention to leave (ITL) (Hallaran et al., 2021). A secondary aim was to identify what new Ontario RNs described as the facilitators and barriers to their transition into the nursing workforce. The results of the secondary aim are reported in this paper.

Methods and procedures

A predictive, non-experimental design was used to test the model linking transition, conditions of transition, and new nurses’ ITL. Data was collected using a mailed cross-sectional survey, circulated in the summer of 2015 to a random sample of 700 Ontario RNs within the first 24 months of registration. Eligible participants were registered with the College of Nurses of Ontario (CNO), English-speaking, and educated in Ontario; the inclusion criteria were selected to increase homogeneity for testing the model. The random sample mailing list was generated by the CNO using the aforementioned criteria and supplied to the researchers. Participants were provided an information letter with the survey outlining a number of ethical considerations including consent, not participating or withdrawing from the study, storage of data, and confidentiality. Return of the completed survey to the principal researcher, using an envelope with pre-paid postage, indicated consent to participation. Approval from a university health sciences ethics board was obtained prior to commencing the study.

The questionnaire consisted of the Casey Fink New Graduate Survey^©, as well as scales measuring self-efficacy, role stress, work-family conflict, job satisfaction, practice environment, empowerment, and ITL. An open-ended question on facilitators and barriers was included. Given the number of responses to the open-ended question, thematic analysis, a descriptive qualitative approach (Vaismoradi et al., 2013), was completed to identify themes related to the facilitators and barriers of transition to practice for new nurses. The themes are the focus of this paper.

The survey responses were entered into a Microsoft Excel^© spreadsheet, and then line-by-line color coding of the data occurred, followed by a re-examination of the given codes to check consistency of interpretation (Thomas & Harden, 2008). The codes were independently reviewed by two coders, by the principal researcher (A. H.) and an experienced second researcher (D. E.) for similarities and differences to help categorize the codes into meaningful groups and generate analytical themes (Thomas & Harden, 2008). Each researcher had previously coded and the secondary researcher (D. E.) had experience using various qualitative approaches and methodologies. Findings from each researcher were consistent and the final themes agreed upon by each researcher.

Results

The response rate for the study was 32% (N = 217). Respondents were primarily female (87%), single (64%) with a mean age of 27 years (range 22 – 54, SD 5.69). These new nurses had worked in RN positions for an average of nine months and worked one job (76%), primarily in hospital settings (75%). The demographic characteristics of the sample were similar overall to provincial statistics reported by the CNO for 2015 (CNO, 2016). The mean transition rating of 6.9, on a scale from 1 to 10, suggested a positive transition. Intention to leave measures were low; however, 45% of respondents reported having left their first job, and one percent reported having left the profession. The remainder of the survey results are published in Hallaran et al. (2021).

Survey respondents were asked to describe facilitators and barriers to their transition into the nursing workforce, and to provide specific examples. Of the 217 surveys reviewed, 196 respondents (90%) provided responses. A summary of the responses is provided in Table 1. The themes that emerged to describe the facilitators and barriers are discussed below, which illustrate both similarities and opposition.

Table 1.

Summary of Responses to Open-Ended Questions.

	Number of Respondents	Word Count	Most Commonly Reported (n)
Facilitators	174	4311	Preceptors or mentors (n = 61)
			Co-workers (n = 39)
			Nursing Graduate Guarantee (n = 38)
			Positive culture or environment (n = 21)
			Previous clinical experience (n = 21)
			Orientation and continued education opportunities (n = 19)
Barriers	184	7896	Preceptor/mentor (n = 41)
			Lack of jobs (n = 39)
			Lack of skills (n = 36)
			Co-workers (n = 22)
			Lack of confidence (n = 18)
			Manager (n = 15)
			Nursing Graduate Guarantee (n = 14)
			Physicians (n = 12)

Facilitators

The most commonly reported facilitators are provided in Table 1. Three themes emerged from the analysis: 1) supportive teams; 2) feeling accepted, confident, and prepared; and, 3) New Graduate Guarantee.

Supportive teams

The theme of supportive teams captured a number of aspects of the workplace that were supportive of new nurses’ transition, which included the sense of a supportive culture, where staff were recognized as friendly, helpful, and the new nurses felt comfortable asking questions. For example, … amazing coworkers who made themselves available to me during any of my shifts. They never made fun of my dumb questions or mistakes but always gently steered me in the right direction. I had a great supervisor as well but it was truly my co-workers who have molded me into a…competent nurse. (RN27) Another respondent wrote, “very supportive staff where I work, have never felt ‘alone on an island’, or that I'm drowning” (RN151). Although respondents identified members of the interprofessional team as support, it was experienced nurses who were most commonly described as the supportive co-workers.

In this positive environment, the new nurse was provided orientation, as well as opportunities for continued education, such as in-services, professional development days, and support for other learning opportunities such as certifications needed for the area of practice. For example, “Workplace orientation… introduction to staff, being buddied for 6 shifts allowed me to feel comfortable on the floor. If you needed more orientation, all you had to do was email the manager for extra ‘buddy shifts’” (RN124). This theme also captures new nurses being supported by preceptors and mentors. Although the terms are not synonymous, the respondents did not distinguish between the two, and the terms seemed to be used interchangeably. Other supports recognized were nursing managers, “a supportive manager means the difference between staying at a job or quitting” (RN7).

Feeling accepted and confident, and prepared

The second theme, feeling accepted and confident, and prepared, captured supportive personal experiences within the transition process as well as personal characteristics that supported them in the process. New nurses recognized that feeling like part of a team, and socializing team members, positively facilitated their transition. Some examples supporting this theme included participating in team functions outside the workplace, “as a new employee, being included in unit's social events and valued as an important member of the team” (RN82) and making friends among co-workers, including other new nurses, as another commented, “making friends on the unit who shared similar experiences to myself - someone to vent to about a tough day” (RN10).

Personal characteristics that the new nurses brought to the transition that they recognized as supportive included their individual characteristics (confidence and ability to cope with stress), nursing education, previous experiences, and existing support systems. One nurse acknowledged the reciprocal relationship between confidence and supportive colleagues, writing “they are willing to help, and they also reassure me regularly which really gives me confidence in my knowledge and skills” (RN22).

Nursing education was identified as providing the new nurses with exposure to knowledge and skills needed for nursing practice. In many circumstances, the clinical experiences provided in their nursing education was identified as a positive facilitator for their transition: “Having pre-consolidation with organization currently working with (oriented to unit, charting/paperwork system) and already know some of nurses and doctors” (RN158). This was also echoed by those who were employed in an area they had completed a clinical placement and most commonly their final, clinical placement or consolidation. One nurse responded that she was, “initially hired where I consolidated, OB/GYN, L&D, I felt very welcomed, appreciated, [an]autonomous, preceptor worked with me which was extremely helpful with transition” (RN113).

Beyond experience from educational clinical placements, nurses reported previous clinical work experience in roles such as unregulated care providers as a facilitator. Finally, new nurses identified their personal support systems which helped them transition, including parents, significant others, and friends. In some instances, respondents reported that a personal support person who provided advice, such as a parent, also were nurses.

Nursing graduate guarantee

The third theme of facilitators for transition was Nursing Graduate Guarantee (NGG). This theme focused on the new nurses’ participation in the NGG in Ontario. Some respondents identified the role of the mentor or preceptor, for example, “having a mentor with the new grad initiative and having team leads ensure mentor's assignment wasn't increased due to having a new grad (e.g., not treating new grad nurse as extra staff)” (RN144) and, “having [a] mentor to guide decisions i.e., You can always ask questions and you know the mentor is willing to help and not brush you off or feel like you are bothering them” (RN37). This response also recognizes the value of considering the workload assigned to the nurse within the NGG program as valued by the new nurse.

Other respondents did not identify specific characteristics of the NGG that were most helpful, but broadly recognized that participation in the program was supportive to transition. For example, “participating in new grad guarantee program helped me transition and become a confident novice nurse” (RN108), and “…allowed an easier transition into working independently” (RN38). The support of the NGG over time was also recognized as a facilitator, where one respondent stated, “the new grad program was great as I was able to learn over three months what the job entails” (RN176). Barriers In comparison to the facilitators, additional respondents provided comments to the open-ended question on the barriers of transition, and the volume of content provided regarding barriers was almost twice as large as that provided for facilitators. The most common terms used to describe barriers are provided in Table 1. The thematic analysis process revealed four themes: 1) feeling unprepared; 2) discouraging realities and unsupportive cultures; 3) lacking confidence/feeling unsure; and, 4) false hope.

Feeling unprepared

The theme, feeling unprepared, captured sentiments of feeling unprepared for practice, feeling unprepared for the workforce, and a lack of orientation or continuing education. Requisite skills and knowledge needed for practice, such as caring for central lines, initiating intravenous access, and phlebotomy, were specifically identified by new nurses. Some respondents reported feeling unprepared for other aspects of nursing practice, such as having a full patient assignment, high patient acuity levels, communicating with physicians, or being placed into in-charge roles. Two nurses commented, “expectations that you know the "system" for example requisitions, referrals, "normal" for our area” (RN12), and “having to communicate with physicians, take orders, etc. from day one when as a student we are never allowed to” (RN15).

Other nurses suggested that orientations or continuing education opportunities within their workplaces were lacking, or in some cases not provided, and that this could have helped them gain the knowledge and skills they felt they needed for the practice setting. The responsibility of being a nurse was also noted, with one nurse acknowledging to “not fully understanding the huge amount of responsibilities that comes with this job (i.e., understanding a small error can cost a life)” (RN180).

Similarly, nurses reported feeling unprepared for entering the workforce and adjusting to nursing work. Writing resumes and interviewing were specific examples provided that they felt unprepared for, but other realities regarding the workforce were also revealed, such as difficulty in finding full-time work, applying for jobs and hearing no responses or offers for interviews, and in some cases, discouragement as posted vacancies required nursing experience in order to be considered for a position. One respondent commented,

No one prepared me for entering the workforce. In nursing school, we had one day to speak about resumes, cover letters, etc. but no one really talked about how and where to apply. This was especially frustrating when everywhere I applied to, needed 2–5 year. Also, the NGG was never discussed in detail and I was unaware of what exactly it was. (RN2)

Discouraging realities and unsupportive cultures

The theme, discouraging realities and unsupportive cultures, captures concerns identified by new nurses relating to practice setting realities, challenges with preceptor/mentor, bullying, lack of management support, and unsupportive culture within the workplace. The term realities were used by the researcher to capture comments about current workplace expectations, such as workload, patient assignments and the related practice expectations of employers. The new nurses reported heavy or high workloads with varying numbers for nurse-to-patient ratios. Some comments included, “Unrealistic ratios (6 patients to 1 RN)” (RN57); “Heavy patient load - having 4 complex patients on days and 6–7 on nights made it extremely problematic and hindered ability to problem solve” (RN10); “People judge you for staying late to finish work (or skipping breaks) which makes me avoid filling out overtime. I am never out on time” (RN19).

The requirement or expectation of employers to be able to provide care to the assignment patients, while trying to adjust to a new workplace and learn many new skills was a barrier for new nurses, with one nurse writing, “unfair expectations to perform my own duties as well as other RNs/RPNs duties without extra time or pay” (RN92). Adding to these expectations were challenges with preceptors or mentors, who were reported as unsupportive, difficult to work with, and/or unapproachable. “Burnt-out preceptor - not interested in teaching and not passionate about her job anymore e.g., telling me I can do nursing tasks on my own and not helping” (RN10); “Not always having available, knowledgeable or willing mentors past the orientation period” (RN92). Similar comments were made about other nurses, management, and members of the interprofessional teams, specifically physicians. One nurse shared, “there is one surgeon who literally yells at you if you ask him whether he wants Ringer's Lactate or Normal Saline (that's us trying to get a verbal order)” (RN140). Respondents used the terms horizontal violence and bullying in their remarks, and share the following comments,

“Older nurses bullyish at workplace; no support from other nurses; attitude and blaming from other nurses” (RN49);

“A couple co-staff who bully” (RN13);

“Criticism from other nurses (horizontal violence)” (RN101);

“Nurses have to be afraid to page or talk to a lot of doctors because they may yell at us. There have been many times where I've felt like crying after a shift and many times that I have cried, a lot” (RN140).

Other comments were broad and identified an unsupportive unit or culture within the workplace, that included “gossiping, lack of positivity” (RN21), and,

“A lot of negative talk in the breakroom about unit politics, how terrible job was” (RN10);

“Judgment by senior nursing staff that new nurses are incompetent. Difficult personalities and expectations when required to interact with doctors” (RN114).

Lacking confidence/feeling unsure

The theme, lacking confidence/feeling unsure, captured within this theme were personal struggles encountered by the new nurses, expressing a lack of confidence to provide nursing care. Some respondents expressed the lack of confidence in managing acute patients or unfamiliar situations, workloads and performing nursing skills.

“Lack of self-confidence and the doubt in my abilities can be debilitating” (RN99);

“I sometimes feel unsure of my abilities and/or family/patient relationships” (RN24);

“My self-doubts about being able to put what I learned in school into practice and fear of not reacting quickly or properly to certain situations” (RN30);

“Lack of confidence, I was scared to start working in the emergency department. After school I had trouble sleeping, nightmares, etc.” (RN171).

False hope

Lastly, the theme of false hope emerged as a barrier to transition. Captured within this theme were concerns over the NGG. Despite the respondents who had participated and identified the NGG as a facilitator to transition to practice, other respondents did not have the opportunity to participate. Some respondents expressed a lack of awareness regarding the NGG, whereas other concerns related to the NGG processes and conditions, such as “pretty unhelpful if you were unable to pass the exam on the first try [or] you no longer qualified as it had been more than 6 months since you graduated” (RN194) and competitive, for example, “[the] NNG was in my opinion false hope, I applied to every position possible and did not get one call back” (RN18).

Those who had participated in the NGG and identified it as a barrier focused on the NGG not being long enough or not very helpful. In one instance, a respondent recalled being, “forced to come out of training due to a lack of adequate staffing” (RN29). Another nurse said, “after minimal orientation time in the new grad initiative being pooled into the clinical resource team, meaning you are expected to be fully capable to work on each floor despite the time between scheduled shifts” (RN19).

Discussion

The thematic analysis of comments related to perceived facilitators and barriers to transition were similar to previously reported findings in the literature. Respondents shared comments that illustrated the important role that co-workers, mentors and organizations play in supporting their transition to the workplace, along with their prior experiences in work and schooling. Yet, respondents also shared concerns of lack of support, making mistakes, lack of confidence, feeling unprepared, and negative work cultures, including bullying faced by new nurses. The volume of comments provided suggests that new nurses are eager to provide feedback on their transition experience. In fact, several respondents wrote comments thanking the researcher for the study. The examples provided rich illustrations regarding the various hardships new nurses undergo while transitioning to practice and the effect these can have on them, including influencing their decision to change jobs.

Reflecting on the facilitators to transition, the themes reinforce the importance of an orientation period, mentors, preceptors, supportive co-workers, and new nurses socializing on the unit as part of a healthy work environment. These facilitators to transition were expected and coincide with previously reported facilitators for transition (Phillips et al., 2012; Regan et al., 2017; Rush et al., 2015). As part of a Canadian study, Regan et al. (2017) completed interviews and focus groups with new nurses and nursing leaders who reported that orientation, mentors/mentorship programs, and supportive and safe work environments facilitated transition. The third theme from the present study, NGG, is unique to Ontario, yet the role that transition or residency programs have in supporting new nurse transition is well recognized internationally (Rush et al., 2019).

Past experience on a unit contributes to new nurses feeling accepted and confident. This experience included prior clinical placements as a student, most notably the final clinical placements or consolidations, and in some instances included working as an unregulated care provider. Phillips et al. (2012) suggested that previous work experience may influence a new nurse's confidence and transition. Examining whether pre-registration employment affected transition, these researchers administered a cross-sectional survey with Australian new nurses (N = 392). Measuring transition on a 1-item scale, and comparing transition scores to the type of work, Phillips et al., reported transition scores were significantly higher for those who had undertaken paid employment compared to the non-workers (p < .05), but that scores did not differ between types of employment pre-registration, such as clinical versus non-clinical. They concluded that the type of work experience was not important but that generic, transferable skills acquired from working were key to the successful transition. In our study, the respondents did not indicate that any past work experience facilitated their transitions, but specified nursing experience in the same environment as supportive to their transition.

In review of the barriers to transitions, the themes were not surprising to the researchers yet disheartening. Reported lack of confidence and workloads with high patient acuity levels were identified. Thematic findings were consistent with scaled questions in the survey, where high proportions of respondents reported difficulties in transitioning as a lack of confidence (n = 130, 60%) and workload (n = 125, 58%) (Hallaran et al., 2021). Concerns of new nurses lacking confidence have been reported for many years. Ortiz (2016), who interviewed 12 new nurses working in hospitals in New York state, reported that all participants lacked professional confidence during their first year of practice. These new nurses were found to have fluctuation in their confidence, which was dependent on exposure to situations in the workplace, and suggested that gaining experience was instrumental to developing confidence (Ortiz, 2016).

New nurses’ concern of workload can be found in the literature. In a mixed-methods study conducted in Ireland (Suresh et al., 2013), themes which emerged from new nurses included excessive workload, difficult working relationships, and unmet clinical learning needs. Excessive workload included concerns expressed by the new nurses of non-nursing tasks, dissatisfaction with low staffing levels, and not having enough time to meet the emotional needs of clients (Suresh et al., 2013). In Canada, Regan et al. (2017) reported new nurses’ concerns over heavy workloads, which affected their ability to practice safely, and recognized the longer standing issue of units being inadequately staffed.

Unfortunately, respondents in our study also described bullying and horizontal violence. The terms bullying and horizontal violence are found in the literature related to the experiences of new nurses. Blackstone et al. (2018) define horizonal violence as involving “bullying, and psychological violence among RNs in equal positions of authority” (p. 973). Recent studies have examined incivility, identified as a “low-intensity behaviour that occurs along a continuum that can escalate to bullying and HV [horizontal violence]” (Blackstone et al., 2018, p. 273). In a national, longitudinal survey amongst new Canadian nurses (N = 920), Laschinger et al. (2016) reported that a large proportion of respondents experienced some sort of incivility from physicians, co-workers, and supervisors. Laschinger and colleagues suggest that the findings are disturbing, and that action is needed from leaders to promote respect and civility in the workplace. Thematic findings from the current study are also troubling, and support the call for further action in the workplace to reduce bullying and horizontal violence.

Limitations

The overwhelming number of responses to the open-ended survey question warranted a thorough analysis of thematic content but was unanticipated at the onset of the study. Thus, the use of data collection by a questionnaire to inform the thematic analysis is a limitation. The recommendations provided are based on the researchers’ understanding of the themes, examples provided by the respondents, and existing literature. Future studies should directly ask new nurses to share their recommendations to improve their transition to the workforce. Furthermore, use of other research approaches that support dialogue and opportunities for clarification of the new nurses’ perceived facilitators, barriers, and recommendations for improvement is suggested.

Recommendations

Seven recommendations directed to nursing leaders in practice and education are outlined below, informed by the thematic analysis and available world-wide literature. The recommendations provided strengthen existing strategies and consider new ones to support new nurses’ transition, while also presenting opportunities for partnerships between employers, clinical practice leaders and educators.

Expectations for practice

The new nurses reported heavy workloads. The requirement or expectation of employers that new nurses provide care to assigned patients while trying to adjust to a new workplace and learn many new skills was a barrier to their transition. Expectations for practice can vary between health care settings and jurisdictions; however, new nurses enter practice with entry-level competencies that are general and broad, and serve as the foundation for nursing practice (CNO, 2019). Comparing these entry-level competencies to the expectations of employers and the needed competencies in the workplace, employers can target orientation to meet the needs of new nurses as well as the needs of patients and the employer. Furthermore, setting realistic expectations related to workload may mitigate role stress experienced by new nurses, and in turn, support positive transitions. This recommendation is especially important for new nurses in light of staffing model changes that may have occurred to address the COVID-19 pandemic.

Transition programs

Evident in this study, the NGG can support the transition of new nurses, yet was not available to all new nurses. Nursing leaders are well positioned to advocate for policy that supports new nurses transitioning to the workforce, such as the NGG, for all new nurses and to advocate for similar programs in other jurisdictions. In addition to maintaining, improving, and expanding initiatives such as the NGG, there is also an opportunity to integrate evidence-informed practices into transition programs for new nurses.

Combining our findings with existing literature, we recommend that transition programs include the following components: orientations that are a minimum of four weeks in length (Rush et al., 2015) that include supernumerary time (Ohr et al., 2020); reasonable workloads (Halpin et al., 2017); role expectations and role clarity to reduce role stress; continuing education opportunities to support knowledge and skill development; an assigned supportive mentor or preceptor (Labrague & McEnroe-Petitte, 2018; Rush et al., 2015); and, continued structured support to new nurses for up to nine months (Rush et al., 2019).

Strategies to address bullying

Additional considerations for promoting supportive work environments for new nurses include fostering collegial relationships and addressing bullying or horizontal violence. Survey respondents wrote comments about how valuable co-workers’ support and interprofessional collaboration was to their transition, yet they also voiced concerns of bullying and horizontal violence. Nursing leaders have an important role for supporting all nurses. Leaders and role models for new nurses are diverse and may include clinical managers to educators to informal leaders within their area of practice. Therefore, we recommend that all leaders understand and address the concerns of bullying and horizontal violence, through policy development and by clearly articulating the expectation and consequences for all team members. Leaders also need to role model professional behavior and create opportunities for discussion and education.

Until such a time when bullying does not take place, nursing leaders can advocate for transition programs as a strategy to help address the concern of new nurses experiencing bullying and horizonal violence. Rush et al. (2014) reported that the prevalence of new nurses experiencing bullying was similar between those in a transition program and those not in a transition program. However, new nurses participating in a program were able to access support. Therefore, an additional recommendation for transition programs is to include content and skills on bullying prevention strategies (Rush et al., 2014). For example, Dyess and Sherman (2009) suggested preparing new nurses to help them react appropriately to horizontal violence, such as scripted responses and using role-play. Such learning, coupled with effective workplace approaches to thwart bullying amongst team members, has the potential to stop ongoing cycles of bullying and horizontal violence.

Preceptor/mentor development

To support any transition program, the role of the preceptor must be valued and developed. In the present study, new nurses identified their preceptors and mentors as facilitators to their transition, providing encouragement and helping to make the environment welcoming. Oritz (2016) reported that the positive feedback from preceptors promoted new nurses’ professional confidence. In addition, new nurses identified preceptors/mentors as an important source of personal support during their initial work life (Ohr et al., 2020).

Formal preceptor development and education for experienced nurses assists them to support new nurses through constructive feedback and encouragement of critical thinking, and in turn, enhances preceptor satisfaction and retention (Rush et al., 2019). Given the valuable role of the preceptor in supporting new nurse transition to practice, development and support of preceptors is an important aspect of planning new nurse transition, and related recruitment and retention. There are many resources to use to help develop a preceptor program, including use of online modules and programs to support staff and organizations (Kinsella et al., 2016). Preceptors have reported that online preceptor support programs provide flexible for working nurses, while also providing an opportunity for professional development, and acquiring technological skills which were helpful to their role of preceptor with millennial learners (Myrick et al., 2011).

Self-Efficacy

The development of self-efficacy should include skill development needed for clinical practice, yet given the concerns of bullying found in this study, development of strategies for managing challenging colleagues is also an area for consideration. Learning centers (for example, nursing labs) can provide a safe environment for development of self-efficacy, with comprehensive overviews, opportunity for hand-on practice prior to completing the program and beginning the transition, and include scenarios of inter- and intra-professional conflict. In particular, new nurses have related their experience with use of high-fidelity simulation, with realistic scenarios, in nursing education to their ability to practice with competence and confidence (Brown, 2019).

Preparation for the workforce

Helping nursing students prepare to enter the workforce is an activity that educators need to energetically undertake in partnership with local healthcare employers, as well as with career services offered by the academic institution. Strategies may include, 1) inviting local employers to discuss role expectations and human resource processes (i.e., applications, what they look for in a resume); and, 2) working with career services to help facilitate activities such as job fairs, workshops for resumes, and even mock interviews. Such strategies may be offered as workshops and events, or incorporated into existing courses offered at the end of programs.

Final clinical placements

The final clinical placement for nursing students, sometimes referred to as senior practicums or consolidation, was identified as a facilitator for transition, especially for those new nurses who became employed in the same unit or department as their final clinical placement. Despite the vast amount of research related to new nurses and transitioning to practice, there is little evidence regarding nursing students’ perceptions of readiness for practice (Jamieson et al., 2019). In a study of senior nursing students (N = 295) in New Zealand, Jamieson et al. (2019) reported that students suggested more time in clinical placement and more simulation would help them feel better prepared for practice.

Depending on the clinical placement model used by nursing schools, selection of appropriate settings and support for those who are with the students during the placement, such as clinical instructors for group placements or preceptors in a one-to-one preceptored placement, should also be considered. Clinical practice experience was reported to be an antecedent for practice readiness by Mirza et al. (2019) in a recent concept analysis study. Given the importance of clinical placement in nursing schools, and the recruitment opportunity placements present for employers, the quality and quantity of clinical placement hours need further investigation, along with understanding the role that a final clinical placement has on new nurses’ transition. Changes made to clinical placements due to the pandemic heighten the need to further explore the implications on new nurse transition.

Conclusion

The reported facilitators and barriers by the survey respondents provide insight into what new nurses encounter when transitioning into the workplace. The respondents identified a number of facilitators to their transition, yet also identified barriers that provide insight into their experience as well as opportunities for improvement. A holistic approach is needed to support these new nurses, which includes the work environments, personal factors, policy and education. This study identified a number of strategies that are in place and are facilitating the new nurse transition. It is important not to lose sight of these accomplishments despite the areas of concerns and barriers to transition found. In keeping with the voice of the new nurse,

Though 90% of my colleagues are positive team members there is still 10% that just make you feel bad for doing things well. For e.g., my patient and their family thank me for a great job during my shift, my negative colleagues start making remarks and doing eye rolling. All I want is to make sure my patients are satisfied with my care (RN40)

Nursing leaders and educators have professional obligations to support our new nurses transitioning into the workforce. We must seek and create opportunities to support the transition to practice and to foster supporting and healthy work environments. These opportunities can include setting realistic expectations for new nurses, advocating for transition programs and orientation, addressing concerns of workplace incivility, and supporting preceptor development. Educators have resources and expertise to implement strategies to develop self-efficacy of senior students and help prepare them for entering the workforce, and can work in partnership with nursing leaders to support the transition into the workplace.

Author Biographies

Amy J Hallaran, RN, PhD, is a Professor at Trent/Fleming School of Nursing, Fleming College.

Dana S Edge, RN, PhD, is (retired) Adjunct Associate Professor at School of Nursing, Queen's University.

Joan Almost, RN, PhD is an Associate Professor at School of Nursing, Queen's University.

Deborah Tregunno, RN, PhD is an Associate Professor at School of Nursing, Queen's University.