Phenomenological Study on Professional Role Transition of New Graduate Nurses

Introduction

Nurses across the globe have widened their scope of work, roles, and responsibilities. There is still concern about how they are being nurtured to handle these role changes. Nursing may be the only profession where the student nurses as well as the graduates are looked upon as a significant member of the healthcare team due to the pressing demand brought by acute staff shortage.¹ This acute staff shortage and the demands of the curriculum result in a complex and difficult experience for novice graduate nurses as they transit to the role of a registered nurse from that of a student. Inability to cope up with the work pressure results in high turnover rate of nurses in hospitals. The retention of new nurses is vital as they play a significant role in patient safety and quality of care.²

A novice nurse often encounters various challenges in their journey towards their professional excellence.³ The transit from the life of a student nurse to a skilled professional can be a stressful experience for a novice nurse. Even though they are well grounded in the nursing theory, they require time and guidance to acquire necessary skills and apply them to the demanding patient needs and situations. The academic learning and the reality in their work environment are also very different.^4,5 Many studies have reported that the novice nursing graduates lack enough proficiency to render excellent nursing services at the beginning of work.⁶

As the healthcare system faces a huge demand for staff nurses, the newly graduated nurses may have to take up an independent position without adequate clinical and critical thinking skills, which can adversely affect the quality patient care and also the self-confidence of novice nurses. They perceive that they are inadequately prepared to face this reality and can feel insecure.⁷

It is evident that the novice nurses experience conflicts as they undergo transition which has been represented as a syndrome called ‘reality shock’.⁸ The new graduates often sense the reality shock when they are unable to assimilate the theoretical knowledge and skills into their daily professional practice, and realize that the theory learnt in nursing schools differ from the professional nursing practice in healthcare institutions.^8,9

Transition for a newly graduated nurse is comprised of personal, professional, intellectual and emotional changes, along with skill and role changes.¹⁰ Even though several studies have addressed the issue of transition in clinical practice at different stages, there have been a shortage of studies conducted in Indian context. Thus the researchers wanted to identify the phenomenon of transition of newly graduated nurses in India to understand the adequacies of their educational preparation and to suggest measures that enable transition to be a safer and enjoyable process. The present study used Judy Boychuk Duchscher's theory of transition (2008) as the framework.¹¹

Materials and Methods

Study design

A phenomenological research approach was used among the staff nurses who were working at a tertiary care hospital. Ethical approval for the study was obtained from the Institutional Ethical Review Board. An interview technique was used to collect the data. The data was collected in two phases. Phase I: Focused group interview, and Phase II: Individual interview.

The participants of the study comprised 10 staff nurses who fulfilled the inclusion and exclusion criteria set for the study. The subjects were selected through the purposive sampling method. The inclusion criteria considered were the willingness of nursing staff to participate in the study and share their experience, having experience of more than one year in intensive or critical care units.

A descriptive phenomenological research design was adopted as both the philosophy and methodology and the four steps of descriptive phenomenological studies including bracketing, intuiting, analysis and describing were used by the researchers. Even though it was difficult to achieve bracketing totally, researchers attempted to bracket out the world to confront the data in pure form. In the second step intuiting, the researchers kept an open mind to the meanings ascribed to the phenomenon by those who have experienced it. The analysis phase comprised of selecting significant statements, grouping and making sense of the vital meaning of the phenomenon. Finally, in the descriptive phase, the researchers tried to define the phenomenon. The investigators identified and clarified their interest in the study and maintained initial reflective notes in an effort to bracket the phenomenon under study.

Data collection

The researchers prepared a semi-structured interview schedule based on the theory of Stages of Transition by Judy Boychuk Duchscher.¹¹ The content validity of the tool was established by seven nursing experts. Formal written permission was taken from the authorities for conducting the study. The purpose of the study was explained to the participants who met the eligibility criteria and written consent was obtained. Data was collected outside the work environment according to the subject’s preference. Before conducting the actual interview, the investigators had an introductory meeting with the participants to establish trust between the researcher and the participants.

The focused group interview was conducted for a duration of 60 minutes and the moderator created a permissive and nurturing environment so that the participants were encouraged to speak freely about their experiences. In phase II, two sessions of semi-structured, individual, face-to-face interview was conducted and the duration of each interview was 45 to 60 minutes.

During each interview, the participants were asked open-ended questions to stimulate conversation to ensure full, rich data. The questions were intended to clear or to probe and thus a detailed discussion of the topic was invited from the participants. Brief periods of silence were maintained during the interview process and this reflective period allowed the participants to fully explain or disclose their thoughts, conceptions, or feelings without feeling rushed or refrained. Field notes were also used during the interviews to record any significant observations and main content ideas without diverting from the interview itself. Data collection was continued till the data saturation. Data saturation was defined as ‘the time when data collected showed no new information’. Permission was obtained and the interviews were audio-taped and transcribed into verbatim.

Trustworthiness of the study

Lincoln and Guba’s criteria of credibility, dependability, conformability and transferability were used to establish the trustworthiness of the study. An effective trust-based relationship was established between the researcher and the participant and prolonged engagement as a strategy was adopted by the researchers to ensure indepth understanding of the phenomenon and saturation of important categories. The researchers maintained an audit trail to document all methodological decisions and the evolution of the themes. Data from the interview was presented to the participants after analysis as a validation strategy.

Data analysis

The transcribed notes were read several times by all the researchers to make certain that the content and the essence of each interview was fully understood. Seven steps of analysis by Colaizzi’s (1978) were used and included: Reading the verbatim and listening to the audio scripts several times; extracting significant statements; formulate meanings; organize into an array of themes; integrate result into a comprehensive description of the study; formulate an intensive description of the phenomenon; and member checking to establish credibility.

Results

Characteristics of the participants

The participants in the study were in the age group of 20- 41 years. All the participants were females, six of them were married and four were single. Eight respondents were working in CCU/ICU, one in CTVS ICU and one in Neuro ICU. All the nurses reported that their area of clinical practice was not as their choice, but as per the decision from the higher authorities. All the participants had more than 12 months of work experience in the critical care unit and were designated as registered nurses.

Themes emerged

The researchers attempted to make a meaning of the professional role transition of new graduate nurse and had used the theory of transition by Judy Boychuk Duchscher as a framework. The theory describes three stages of new graduate nurse’s experience as he or she transit from novice nurse to skilled nurse in critical care, such as Doing, Being and Knowing.¹¹

Doing Stage

This stage refers to the initial period of role transition of new graduate nurses which encompasses the first 3-4 months of their experience.¹¹ The transition from a student to a professional with new sets of expectations and accountabilities posed several challenges to them. The new nursing graduates were excited to work in the beginning, but quickly realized that they were unprepared for their new role.

Being scared

Enhanced level of responsibilities and accountabilities arising from the new role were overwhelming for the novice nurses and they were scared to take care of unstable and mechanically ventilated patients and found the practice setting as a scary one, till they became familiar or gained confidence.

“Initially I was scared, ventilator and receiving patient especially from OT…. In night duty, I had never done… so scared. I felt, I have more responsibilities for patient care......” [P2]

Being stressed

The graduates expressed severe stress initially in their practice and felt they were not confident enough to care for clinically unstable patients. Limited experience in applying their knowledge and skill and unpredictable clinical context challenged their quivering confidence. Many of them expressed high levels of stress as they were expected to multitask which included, rendering nursing care, attending to the physicians, interacting with family members.

“It’s highly stressful. How to take care of patient…. interact with doctors, their reactions…...Multitasking, it was stressful. Sometimes attenders, patient, doctors ask at a time…. Initially, difficult for me. Ahhhh………. “[P9]

Reality is different

All the participants encountered difficulties in their professional transition as they found a gap between their expectation about their professional role and their actual role in the real world. They found themselves incapable of taking simple decisions and felt they were not appreciated in the healthcare system. They felt a need for a more supervised practice during their student life.

Whatever I gain in theory was enough…. Education is ok but I think more practices are needed ... …... I had so many expectations but reality is difficult…... Simple paracetamol giving, GRBS - if more than. We can’t decide by ourselves, Sometimes, I feel disappointed and want to discontinue and nobody appreciate what we do. Feel very bad…” [P4]

Learn, Learn, Learn

As the new graduate nurses found their new role challenging, they identified their need to learn more to adapt themselves to the new setting. They tried to learn from their seniors, doctors and from internet and tried to clear their doubts. They were mainly concerned about their tasks, understanding what to do, how to do without errors and completing the task on time.

Fortunately, the seniors also will help and try to manage. If I don’t know, I will ask seniors …... If not, I will refer books, net, need to learn more … …” [P1]

In this initial stage, all the participants were scared and stressed due to their inability to adjust to the demanding nature of the healthcare system where they were supposed to multitask, with a disparity between their expectation and the reality in the clinical setting. They felt that they were not competent enough for their new role and tried to accommodate by learning in all possible ways.

Being Stage

The next four to five months of their clinical practice were characterized by an improvement in their knowledge, confidence levels and skills to provide quality care. They became comfortable in their new roles by nine to twelve months and realized themselves as being trusted by their senior staffs and other healthcare members. The themes emerged were, gaining confidence and trustworthiness.

Gaining confidence

During this stage, the new graduate nurses found themselves complacent with their new roles and responsibilities and this new level of comfort allowed them to use their critical thinking and decision-making skills for planning and implementing appropriate and effective interventions while providing care. They found that they could communicate well with other members of the health care team.

“It was easy... Patient care improved; frustration was reduced.... Competency developed. Improved IPR with physiotherapist, doctor, etc. First, I did not talk, then I use to talk and now able to interact with them…” [P2]

Trustworthy

During the initial stages of their practice, the new graduate nurses found that they were constantly checked by their seniors and were not trusted. As the months passed, they found that they were trusted by their seniors and they were assigned with major roles and responsibilities.

“Yes, I am… Initially they instructed me and rechecked… but now they trust. Every procedure they won't check, and were given major works...” [P7]

Knowing Stage

This phase encompasses the final stage of transition of the new graduate nurses in their professional role. By the end of 12 months, all graduates had attained a relatively reliable levels of comfort and confidence with their roles, liabilities, and daily schedule. The final stage of transition was marked by an enhanced level of knowledge and confidence, a desire for higher education and professional growth to improve their professional identity and to empower themselves.

The themes emerged were:

Yes, I know

All the participants reported reduction in stress levels and enhanced capability to deal with their roles and responsibilities. They could answer their juniors and were able to assist others with their workload.

“Responsibility increased, improved relation with my coworkers…I am capable enough. Stress level reduced & Personal life can handle…Able to take decision making and what to do for the patient….” [P5]

To be empowered

During this stage, all the participants were highly motivated to explore their knowledge and professional experiences. They wanted to advance their profession through continuing educational programs and higher education and felt a need to be empowered in the healthcare system.

“Professional growth / higher education…yes…... Definitely we need more education, update our education… if such it will be good enough…...” [P10]

Discussion

Transition is an individualized process occurring over an undetermined period of time.¹² In the initial stages of transition, the complexities of healthcare system, workload and the expectations from the seniors quivered the confidence of newly graduated nurses. Rapidly changing clinical contingencies, the fluctuations in the clinical status of critically ill patients and the inability to identify these changes made them feel that they were not competent enough to care for clinically unstable patients. This finding was corroborated by the findings of a descriptive phenomenological study which reported that the new graduate nurses were challenged to function as a qualified nurse as they were not equipped with adequate clinical skills and knowledge to render nursing care for critically ill clients. They felt that they had acquired theoretical knowledge through their education, but required some time to apply the knowledge into practice.¹³ These findings highlight the need for equipping the student nurses with the necessary skills to identify and manage a deteriorating patient.

Majority of the participants expressed that there was a wide disparity between their expectation about their new role and the reality. Similar findings have been reported by a study on transition of health care assistant to student nurse which identified culture shock as one of the emerging themes. The realization that they were not prepared to meet the challenges in the complex system and professional responsibility and accountability demanded from them resulted in culture shock¹⁴ and has been addressed as a syndrome called ‘reality shock’ by Kramer.¹⁵ Similar findings were reported by a qualitative study which identified that the novice nurses had to deal with confrontation about competence and technical ability and they were not prepared to provide care in complex settings.⁸

In the present study, the participants reported high levels of stress during their initial phase of clinical practice and this could be due to inadequate skills and sophisticated technologies used in critical care environment. The researchers feel that this is an important issue to be addressed and has been cited as one of the influential variable affecting the new graduate nurse’s decision to quit the job.¹⁶ Similar findings were reported in a qualitative study in which the respondents expressed high levels of stress during the first six months of transition.¹⁷ The participants expressed that the stress of professional life affected their family life too, but one among them mentioned that being a timid person, the work place stress helped her to become stronger, bolder and was able to communicate effectively in her personal life.

During the second phase of transition, the participants expressed an upsurge in knowledge, confidence, and clinical skills. These finding are in accordance with the theoretical framework by Judy Boychuck and the newly graduated nurse has progressed from Benners’ novice level of competence to an advanced beginner.^11,18 During this phase, they felt comfortable due to their familiarity with the role and responsibilities, but may need assistance in making complex decisions.¹⁸

During the final stage of transition, the newly graduated nurses maintained a balance between the workload and expressed a reliable level of comfort and confidence. They expressed a need for higher education and other educational preparations to empower them. Intrinsic tendency towards progression and advancement of career are the characteristics of this phase.¹⁹ Addressing their professional aspirations, and supporting and guiding them in their career and educational plans will result in long-term commitment to the profession.

Conclusion

The results from this qualitative study confirm the findings of previous studies that the transition from an educational programme to the professional practice setting is stressful. As shortage of nurses continue to be an issue, new graduate nurses are the primary pipeline to meet the needs of the workforce. This can be achieved by a mentoring programme by competent nurses to enhance the self-esteem, confidence, professional job satisfaction among new graduates which can strengthen the nursing profession.

Conflict of interest

Nil