Graduate Nurse Transition to Practice, and Identified the Concern That the Transition of
Graduate Nurses
Introduction
The integrative review of the literature for this thesis is guided by the synthesis of frameworks
elucidated by Whittermore and Knafl (2005), Taraco (2016a), and Taraco (2016b). The
integrative literature review includes a review, a critique, and a form of meta-synthesis of the
literature targeted at a particular goal or purpose (Taraco 2016b). It is known as ‘integrative”
because its function is to form the findings into a unified whole resulting in new frameworks or
perspectives (Taraco 2016b).
The hierarchy of levels of evidence places meta-analyses and systematic reviews at the apex or
highest form of evidence; however, integrative reviews are regarded as more comprehensive
methodologically. Systematic review evidence is considered most reliable because it is empirically
based with a focus on randomised controlled trials. Systematic reviews and meta-analyses are
considered equivalent by the NHMRC (1999); however, some argue that meta-analyses are higher
levels of evidence than systematic reviews due to the process of bringing together all of the results
of the studies being examined into one collective statistical analysis (Ross 2012). Others do not
accept this premise and are hesitant to recommend the pooling of results due to the possibility
of significant bias from the different criteria which denote quality for each research design
(NHMRC 1999). The possibility of bias particularly applies to the integrative review method
which is more complex due to the inclusion of diverse primary sources such as quantitative,
qualitative, and mixed-methods research (Whittemore & Knafl 2005). As a consequence, it will
be noted that a structured appraisal tool, the McGill Mixed Methods Appraisal Tool (MMAT
2018) was adopted to appraise all of the studies equally (NHMRC 1999). Consideration was
also given to categorising the findings of the various studies into a rational framework. Proposed
categories can include study design, classification, demographics, and/or chronology
(Whittemore & Knafl 2005; Terraco 2016b). In this study, it was decided to categorise the
studies conceptually, as the current conception of the topic was considered “problematic”. Such
reconceptualisation of a topic is an appropriate aim of an integrative literature review (Terraco
2016a; Terraco 2016b). The aim of this integrative review will now be discussed, including pre-
conceptualisations, the rationale, and the background.
Aim of the integrative review
The specific aim of this integrative review was to review, critique, and synthesise the existing
literature, and to reaffirm the gap in nursing research with regard to the spectrum of factors and
perceptions that have an impact on graduate nurses and their passage to becoming a
competent professional nurse. How do nursing students successfully transition to graduate
nurse? There is ongoing concern that undergraduate education does not acknowledge the
reality of clinical practice, and portrays the health care system as perfect. As a consequence,
graduate nurses upon practicing as a registered nurse for the first time are subject to a perverse
reality which is far different from the perfection narrative being taught. It is therefore proposed to
reconceptualise the transition phenomenon for graduate nurses from one of “reality shock”, as
depicted by Kramer (1974) and Boychuk Duchscher (2008), to an experience characterised by
preparedness, self-efficacy, and empowerment. This is critical because the reality for health
units is ongoing austerity and a health care culture that often hinders graduate nurse transition.
These impediments also have an impact on the nature of support provided by transition
programs. As a consequence, all undergraduates need preparation for whatever health care
environment awaits them. This includes a thorough background knowledge of the transition
experience, the likely challenges, and the strategies that can be used to navigate their way
through. Some graduate nurses will be fortunate to work in environments that embrace
structural empowerment, while others will need to selectively rely on their psychological capital
and resilience preparedness to thrive. I will now elaborate on the search parameters used to
locate the relevant articles.
Methods
Search Strategy
The CINAHL, Psychinfo, Google Scholar, and Ovid Medline databases were searched in
accordance with the inclusion/exclusion criteria in Table 1. Initially, the search terms were more
complex and included the following, i.e., new graduate nurs* neophyte OR newly registered OR
novice OR transition OR transition to practice OR TTP AND nurs* AND program OR Residency
OR Mentorship OR preceptorship, OR graduate nurse program, self-care, self-advocate,
transition to practice, novice, coping strategies, self-advocacy, self-efficacy, self-esteem,
resilience, hardiness, self-management, and comfort zone. PRISMA, a recognised meta-
analysis checklist, has been used for identification, screening, eligibility, and inclusions, as per
Figure 1. During the identification process, it became clear that psychosocial terms relating to
the empowerment of graduate nurses were infrequently used when discussing graduate nurses.
As a consequence, a less complex search was undertaken with the terms ‘new graduate nurs*’
AND ‘transition’ OR ‘psychosocial factors’.
The search resulted in a return of 1,294 articles from which duplicate articles (n=13) were
removed. The records were subsequently screened in accordance with the inclusion/exclusion
criteria. Screening was a process of removing non-primary research and other artefacts which
were not relevant (n=954). The remaining full-text articles (n=327) were inspected closely for
relevance and rigour (see over the page for relevance and quality criteria), with a final number
of qualitative articles (n=21) and quantitative articles (n=14) eligible for inclusion in this
integrative literature review.
Relevance criteria
The existing paradigms of “reality shock” and “transition to practice” have been reported in the
literature for many‐ years. Reality shock was described by Kramer (1974), who used the term to
refer to shock like reactions produced when new employees realise the discrepancy between
their expectations and reality. Despite evidence and research extending over many decades,
there are gaps with regard to implementing recommendations. It is apparent that there has been
little response by the university sector to the findings of reality shock within the psychosocial
paradigm.
Good psychosocial skills are purported to mitigate against the experience of reality shock;
however, graduate nurses continue to be shocked by the health care culture, rather than being
educated to cope. This integrative review, in concert with the inclusion/exclusion criteria (Table
1), focused on selecting articles that considered psychosocial elements within undergraduate
preparation and during transition to professional practice.
Quality Criteria
This integrative review includes studies with a number of diverse research methods, i.e.,
qualitative and quantitative studies. In consequence of this diversity, it was recommended by
the NHMRC (1999) that a structured appraisal tool be adopted to assess all the studies equally
for rigour (NHMRC 1999). Evaluation of each article was undertaken using the McGill Mixed
Methods Appraisal Tool (MMAT, version 2018) (Hong et al. 2018). This appraisal tool is
particularly relevant to integrative reviews, as it allows assessment of qualitative, quantitative,
and mixed-methods research articles, and is structured and deliberate. Initially, there are two
screening questions for all methods:
Question 1. Are there clear research questions?
Question 2. Do the collected data allow to address the research questions?
(Hong et al. 2018, p. 2).
If the answer is “no” or “not clear” for either question, then further appraisal was to be aborted and
the article rejected. Following these initial screening questions were questions with methodological
quality criteria specific to qualitative, quantitative, and mixed-methods research. Articles were
excluded from this integrative literature review if there was limited transparency with regard to the
research processes used, or if essential components were missing. As all the articles were from
peer-reviewed journals, there were few exclusions linked to a lack of methodological rigour. A score
in the form of a percentage and commentary on each article has been included in the review table
(Appendix 3) for reference. The results will now be revealed below.
Results
Number and nature of studies identified
The results revealed 35 studies (see Appendix 3) representing research from 15 different
countries. Multiple manuscripts emerged from the United States of America (n=8), Australia
(n=5), Canada (n=5), Korea (n=3), Sweden (n=2), and Taiwan (n=2), with single manuscripts
from China, England, Finland, Hong Kong, Iran, Italy, the Netherlands, the Philippines, and
Singapore. There was also one international collaboration between the USA, Scotland, and
Puerto Rico. The methods and methodology are presented in the review table (Appendix 3),
and included:
21 qualitative research studies, i.e., qualitative descriptive (n=8), phenomenology (n=6), narrative
enquiry, case study, exploratory research, focused ethnography, grounded theory, inductive
qualitative content analysis, and qualitative longitudinal study.
14 quantitative research studies, i.e., quantitative cross-sectional studies (n=3), hierarchical
multiple linear regression analysis (n=2), with single studies inclusive of longitudinal and
correlational design, longitudinal confirmative factor analysis, descriptive statistics, randomised
trial with control, prospective longitudinal study, longitudinal study, pre-test/post-test
intervention, and survey enquiry.
There were also mixed-methods studies (n=2) which were included in the quantitative tally.
Analysis of data
Identification and listing of psychosocial factors
The final list of 35 articles were read entirely with the goal of selectively identifying the
salient psychosocial factors that have an impact on graduate nurses in transition. Those
articles that included psychosocial factors identical to those discussed in other articles were
listed as one factor, and any replication is signified by the number of linked references.
Where psychosocial factors were not identical, they were considered to be separate. Using
this criteria, an extensive random list of psychosocial factors were compiled and inserted into
a table for analysis and synthesis.
Grouping of exemplars into subcategories
Theoretical sensitivity was applied to the list of psychosocial factors. This required isolating the
number of psychosocial factors that possessed a unique theme, and where they were
compelling, they were grouped together. The groups were classified using socio-emotive and
psychological constructs. Exemplars include: experience of self and emotions; feelings of fear;
self-efficacy needs.
Categorisation of each sub-category
Further theoretical sensitivity was required to establish the overarching categories to
effectively represent the sub-categories. The final categories were: mental health;
undergraduate education; leadership; and preceptorship.
Categories and sub-categories with explanation
As related previously, there were four categories which emerged. The first of these was “Mental
Health” with three sub-categories, i.e., experience of self and emotions; feelings of fear; and self-
efficacy needs. Secondly, there was “Undergraduate Education” with three sub-categories, i.e.,
unprepared; self-support; and managing situations. Thirdly, there was “Authentic Leadership” with
two sub-categories, i.e., need to feel supported; and need to feel safe. The final category was
“Preceptorship” with three sub-categories, i.e., education needs; negative effects; and positive
effects. I will now explicate each of the categories and sub-categories in detail.
Mental Health
There were three sub-categories of mental health, i.e., experience of self and emotions,
feelings of fear, and self-efficacy needs.
Experience of self and emotions
In their US survey of preceptors (n=42), Shaw, Abbott and King (2018) found that the strengths
of graduate nurses was their caring, collaborative engagement and willingness to work
diligently. This positive perspective was also present in the structured interviews with graduate
nurses (n=15) undertaken in a rural area of the Philippines. Labrague et al. (2019) found that
some Filipino graduates were enthusiastic and excited by the steep learning curve, and keen to
provide the best possible care, regardless of the shock of transition.
Unfortunately, this level of optimism is not universal and the majority of studies continue to
report challenging experiences of self and emotions on a global basis. These challenging
experiences were observed to plague graduate nurses in studies undertaken in Western
Australia (Murray, Sundin & Cope 2019), the cities of Uremia, Ardebil, and Tehran in Iran
(n=14) (Zamanzadeh et al. 2015), Washington (n=34) (Oneal et al. 2019) and Texas (n=15)
(Urban et al. 2020) in the United States, and lastly, the Philippines (n=15) (Labrague et al.
2019). While these were all small studies, as an international collection, they demonstrate that
graduate nurses continue to have numerous misgivings, such as lack of self-assurance, poor
professional efficiency, high anxiety, and feelings of being overwhelmed. In their focus group
study, Tong and Epeneter (2018) made a similar comparison of the stressors in their study of
graduate nurse cohorts from 2003 (n=21) and 2015 (n=22). They demonstrated little change in
graduate nurse experiences over the period with regards to difficulty with communication,
feelings of inadequacy, and their experience of ethical dilemmas. In addition to these findings,
it was identified that graduate nurse’s knowledge of procedures, hospital protocols, and ward
culture continued to be rudimentary, and this further exacerbated their feelings of
hopelessness and their low levels of confidence (Oneal et al. 2019; Urban et al. 2020).
In Chang Gung Hospital, Taiwan, a study of graduate nurses (n=25) revealed that culturally,
there is a “burden of expectations” often characterised by the constant vigilance of other staff
who evaluate their every move and openly compare them with other graduates (Liang et al.
2018). Hostility to graduate nurses was also demonstrated in ten Hoeve et al’s (2018) study in
the Netherlands, in which graduate nurses (n=18) completed written diaries during their first
two years of practice, with over half (n=10) reporting that physicians communicated in a
“demeaning or demanding manner”. Their dismissive behaviour allegedly engendered feelings
of being disparaged and, at other times, invalidated (ten Hoeve et al. 2018). However, as has
been found in previous studies, both internationally and historically, senior nursing staff are
inclined to excuse physicians’ behaviours, preferring not to apportion responsibility or confront
their incivility. This indifference by their seniors further re-affirmed the low status of nursing and
reinforced the graduate nurses’ truncated feelings of worth (ten Hoeve et al. 2018). In order to
mitigate against these obstacles, graduate nurses sought to develop friendships with
colleagues they worked with, and any staff who would be supportive or offer a ‘lifeline’.
Unfortunately, a number of studies revealed that the majority of graduate nurses would find this
goal elusive and, at a time when they were already feeling inadequate as nurses, often
encountered an unsupportive and unfriendly ward culture that severely exacerbated their
transition to practice (Zamanzadeh et al. 2015; Tong & Epeneter 2018; Hatzenbuhler & Klein
2019; Oneal et al. 2019). Attempts to debrief with partners, family members, or friends was
often a fraught exercise as they discovered that most people do not understand the nature of
nursing (Oneal et al. 2019). Camaraderie, communication, and collegiality among co-workers
were cited as protective factors for mental health both inside and outside of the workplace, as
“non-nurses don’t get it” (Oneal et al. 2019, p. 526).
The stress of transition was shown to exist for graduates not only within the professional
domain, but also as an intrusion into their private lives. This intrusion served to increase their
feelings of isolation and dislocation, as many graduate nurses could not separate their private
and professional lives, carrying the frustration and loneliness home with them (Zamanzadeh et
al. 2015; Oneal et al. 2019; Urban et al. 2020). Adding to their social isolation was the impact of
shift work, which resulted in graduate nurses being absent from celebrations that are socially
normative, such as national holidays, religious feasts, and the special milestones of friends and
family (Oneal et al. 2019).
The effects of workplace incivility and horizontal violence from fellow nurses and supervisors
was frequently reported as the most destructive obstacle, and predisposed graduate nurses to
mental ill health. Two empirical Canadian studies investigated the factors influencing graduate
nurses and their successful transition to professional practice in the acute hospital setting. The
first study, undertaken by Laschinger et al. (2016), was a rigorous national two-wave survey of
graduate nurses (n=3,906) undertaken via standard questionnaires with a one-year time
interval. The focus of the two-wave surveys were on ‘situational’ factors, ‘personal’ factors,
‘intermediate outcomes’ and ‘job related outcomes’ such as career turnover intentions.
Graduate nurses who responded to both surveys (n=406) had their responses matched, with
the data revealing that both the work environment and personal characteristics influenced
graduate nurses’ intentions to leave the profession of nursing. The work environment
particularly concerned the research team, with reports by graduate nurses of incivility and
cynicism increasing over the one-year period. These results were consistent with other studies,
with 41.9% of graduate nurses experiencing incivility from physicians, 31% from colleagues, and
24% from their direct supervisors. This mirrored an Australian mixed-methods study in which
Gardiner and Sheen (2017) found that approximately 51% of graduate nurses (n=107) had
stress symptoms resulting from incivility and insufficient support, while others progressed to
symptoms of clinical depression. Mental health effects related to structural empowerment were
examined in a second Canadian study by Wing et al. (2015) in Ontario. Based on Kanter’s
(1977) theory of structural empowerment, a workplace incivility scale was employed to measure
the level of incivility experienced by graduate nurses (n=394) in health care settings. Mediated
regression analysis, using descriptive statistics tied to a predictive non-experimental design,
revealed empowerment to be significantly negatively related to co-worker incivility. Conversely,
mental health symptoms experienced by graduate nurses were positively related to incivility. A
compelling example illustrating this finding is the graduate nurse who considered harming
herself so she would not have to go to work. “I’m not saying that I ever have like suicidal
ideations or anything, but I just remember thinking – I could turn my car into the barrier and then
I wouldn’t have to go to work” (Oneal et al. 2019, p. 522). The need for counselling of graduate
nurses by a psychologist, and increased emotional support from their nursing colleagues, and
inter-professionally, was recommended (Liang et al. 2018).
Although NGNs encountered many distressing or uncertain situations, they found that
when they could control their emotions well, they gained more confidence (Liang et al.
2018, p. 75).
Within the broader international community, it was not an uncommon finding that graduate
nurses were severely exposed during their first year of practice, with mental health risks such as
emotional fatigue and scepticism ever present (Laschinger et al. 2016). As a result, many
graduate nurses re-assessed and reflected on their options which included changing
themselves in some way, requesting allocation to a different ward, or leaving the profession
entirely (Laschinger et al. 2016). In the next section, the recurring theme of “fear” as a
significant phenomenon faced by graduate nurses throughout their transition year, will be
discussed.
Feelings of fear
Fear appeared to be a constant element of transition. Graduate nurses found their new
responsibilities daunting. The fear of taking on the comprehensive role of caring for patients and
all the associated responsibilities was challenging to the graduate nurse; in particular, safe
administration of medications and performance of unfamiliar procedures. There was
apprehension about time management; fear of staff; fear of answering phone calls; fear of
calling physicians and fear of not calling them; fear of not being seen as competent; fear of
making mistakes; and fear of reporting any mistakes.
Graduate nurses’ initial fears of not “fitting in”, and the fear of not being seen as competent
were reported in focus groups (n=29) and key informant interviews (n=5) conducted by
Oneal et al. (2019) in Washington and Oregon, USA. This rigorous study revealed that
perceived or real
pressure from staff was a significant and constant fear (Oneal et al. 2019). Murray et al.
(2019) reaffirmed this perspective in their qualitative descriptive study in Perth, Western
Australia. Semi-structured interviews with informants (n=11) exposed the real possibility that
graduate nurses would compromise patient safety as a result of the pressures to complete their
plan of care as scheduled (Murray et al. 2019). In both metropolitan Groningen in the
Netherlands (ten Hoeve et al. 2018), and in rural communities in New South Wales (Lea &
Cruickshank 2015), graduate nurses were reluctant to ask for help if they perceived that their
colleagues were busy. Paradoxically, there was also the fear-related problem of graduate
nurses not seeking support when they should: “… new graduates often do not ask for
assistance or communicate with other staff if they are experiencing difficulties and they
[Registered Nurses] become concerned when new graduates fail to come near them to seek
support” (Lea & Cruickshank 2015, p. 2831). Unexpectedly, it was not the confident graduate
nurses that failed to speak up when confronted with a situation beyond their competence and
experience, but those who had the least confidence.
Wahab et al. (2017) assembled a purposive sample of graduate nurses from a residency
program (n=9) in Singapore to explore graduate nurses’ accounts of resilience. With a
descriptive design using photo voice, this unconventional study required informants to provide a
photo representative of what resilience meant to them. Graduate nurses were invited to share
their photo and elicit meaning within a focus group session. One graduate provided her personal
graduation photo; the image was designed to evoke a conceptual representation of the general
view held by senior nursing staff that graduate nurses with baccalaureate qualifications should
be competent, and therefore require little transitional support. Another informant provided a
photo of “fear” in the form of the ward telephone to illustrate the fear she had of answering
phone calls, and the steps she took to avoid them. It was not of course the phone of which she
was afraid, but the fears expressed of not feeling prepared or able to respond appropriately to
the questions asked by physicians. Medical staff definitely posed a challenge overall (Liang et
al. 2018; Murray et al. 2019; Oneal et al. 2019). Not knowing when and how to call physicians,
interns, consultants, and specialists engendered significant anxiety (Murray et al. 2019). Ever
present was the fear of the negative repercussions of calling physicians, “being yelled at, even if
it is for good reason”, as reported by one graduate nurse (Oneal et al. 2019, p. 525), or the fear
of not calling them for fear of the potential consequence of inflicting harm if their patient did not
receive timely intervention (Oneal et al. 2019).
In addition to the fear of communication with physicians, there was the fear of interacting with
other health professionals. There was fear and uncertainty of making mistakes and the
associated tensions (Liang et al. 2018; Law & Chan 2015), including the fear of embarrassment
and losing face with their colleagues or seniors if they made the wrong call (Liang et al. 2018).
Such fear and anxiety was portrayed by Liang et al. (2018) as “walking on thin ice”. Instances of
incivility only served to accentuate any fears and negatively influence the quality of care
provided. Investigation of the risk to patient safety from horizontal violence was the focus of a
qualitative phenomenological study by Rosi et al. (2020). Graduate nurses (n=21) who had
graduated from the University of Milan, Italy were interviewed. Informants selected for interview
were not only acute care nurses, but those from any health care context in Milan, and while
slightly outside of the brief of this review, the findings are still pertinent. It was found that where
horizontal violence exists, feelings of fear were accentuated, and the associated stress and
anxiety increased the likelihood of errors and risks to patient safety (Rosi et al. 2020). Further to
this dilemma, graduate nurses were also fearful of reporting “any mistakes” in an environment
where they did not feel supported. This fear further increased the risk to patient wellbeing, as
corrective action would be delayed or the concern not addressed at all (Rosi et al. 2020).
