The power of idealistic-realism: The Prince and Cinderella
Can the research and knowledge around the transition from nursing student to successful
graduate nurse be encompassed in a self-support model? A model (Figure 1) for supporting
graduate nurses with transition that is non-dependent on any contribution from health units is
critical, because this is the likely outcome in the current and future healthcare environment
(Masso et al 2019). Cinderella followed the directions of her godmother (more competent other)
and was successful at returning home by midnight on two successive occasions; however, in
her rush to meet the midnight deadline on the third night, she lost one slipper. This was
paradoxically a fortunate twist as it clarified the need for balance between the two slippers of
idealism and reality. Separately, these qualities are limited and ineffective, as Cinderella found
that she could only walk effectively with a glass slipper on both feet. Nurse teachers have a
tendency to reject the realistic slipper in the hopes of embodying their ideal of perfection, and in
doing so, create a generation of ‘crippled’ graduate nurses who are unprepared for reality.
This final episode reiterates that the likelihood of “inconsistent support”, coupled with the
requisite need for graduate nurses to proactively care and advocate for themselves,
reconceptualises transition to practice. Cinderella had no support from her family, but was
successful in creating opportunities through her own “ways of being”. Cinderella was
determined and able to advocate and care for herself. She transcended her “spectrum of
comfort”, and approached the prince to try the slipper as herself (real), and not as the prince
knew her (ideal). Fortunately, the slipper of reality fit perfectly. The tension between idealism
and reality was reinstated. Wisdom was hence restored.
Preparation of nursing students for the real world of nursing that they will encounter as graduate
nurses will assist with building self-support. Allowing the student to reimagine their own identity
and perception of self through reflection on their own ways of being and spectrum of comfort will
enhance their relationships with staff and others (Blyth et al. 2015). Such opportunities will guide
how they might develop connections (thus extending their zone of proximal development), and
navigate the cultural norms of the health culture, and by what means “fitting in” can be achieved
(Laari & Dube 2017).
The outcomes of this research have been translated to empower (NURS3006) third year nursing
students in the College of Nursing and Health Sciences at Flinders University. My contribution has
built upon Kramer’s (1974) research. It identifies the contemporary harsh realities (Mellor &
Greenhill 2014; Mellor, Gregoric, Atkinson & Greenhill 2017) and their resolution (ASP) derived
uniquely from graduate nurses (Mellor, Gillham & Gregoric 2017; Mellor & Gregoric 2016; Mellor &
Gregoric 2019) who have recently travelled this path. This research and knowledge around the
transition from nursing student to successful graduate nurse can be encompassed in a self-support
model as a bridge of empowerment transforming the nursing student to the “ways of being” and
“spectrum of comfort” of the graduate nurse.
Strengths of the research
The purpose of this study was to generate further knowledge and theory about graduate nurses
in transition. The specific aim was to explore the spectrum of factors and perceptions that have
an impact on graduate nurses and their passage to competent professional nurse in Australia
from the perspectives of graduates and the published research, and to find a model of
addressing this problem. How do nursing students successfully transition to graduate nurse?
Rigorous application and evaluation using the appropriate quality criteria and methods have
been employed during this research to reflect credibility, transferability, dependability, and
confirmability.
In Chapter Two, a discussion of the individual studies was undertaken with regard to the methods
and methodology used. A diverse perspective was gained from graduate nurses who were
participants in the GTM studies. The participants originated from a variety of health care settings in
South Australia, including rural and city locations. Respect for the participants has been described in
detail, as research integrity is contingent with the obtaining of trustworthy responses from
participants. In addition, the studies were completed in consultation with experienced researchers,
as detailed in Appendix 1. Their counsel also provided perspective, advice, and moderation with
regard to the research activities. The interview and focus groups questions were carefully tested and
crafted, taking into consideration the potential for bias. All were reflexively considered. As a
consequence, multiple views were garnered, which revealed rich description of sufficient quantity.
All the studies were demonstrated to have appropriate levels of rigour against established criteria.
Additionally, external validation has been evidenced by acceptance of the five publications in quality
peer-reviewed journals. Such peer review acceptance reinforces the uniqueness of the works
presented for this thesis and provides assurance of originality and relevance.
As an adminicle to the studies presented in this thesis, a comprehensive integrative literature
review was undertaken to establish a contemporary knowledge base, and to reaffirm the
nature of the previous research. As a result, this reaffirmation establishes that this thesis is
unique and has made a significant contribution to the existing body of knowledge around
transition to professional practice. It is anticipated that the conceptual modelling developed as
a result of these studies/ publications will further inform education, practice, and policy
development in Australia and internationally. Further research is recommended to determine
the most effective ways to teach these strategies, to verify their effectiveness, and identify
possible further inclusions that will improve the capacity of graduate nurses to be successful
during transition.
Limitations of the research
There are a number of limitations of which to be cognisant when applying the findings of this
research. The outcomes from this thesis need to be applied judiciously against relevant related
research where appropriate. For the GTM studies, recruitment was problematic at times.
Despite an extensive recruitment effort and close collaboration with health services,
participants were difficult to acquire for interview. In addition, each of the health services
from which graduate nurses were recruited had unique characteristics that may affect the
transferability of the findings. The GTM studies were also limited to South Australia, and
therefore, claims for transferability both nationally and internationally need to be carefully
considered. For the literature review and critical review studies, limitations were also
possible when searching the databases. Identifying relevant peer-reviewed publications
with a focus on “nurses in transition” or “transition programs” was challenging. Titles were
often not transparent and their description insufficient to address the inclusion/exclusion
criteria effectively. While steps have been taken to minimise bias by being actively reflexive,
particularly with regard to the researcher’s personal experience, background, and
interpretations, there may be transparencies that have been overlooked. Personal
experience as a registered nurse, transition program coordinator, lecturer, and researcher
could have had an impact on my ongoing synthesis of the research data and potential bias.
As such, any claims or recommendations made in this thesis will be contextual to the
limitations expressed.
Despite these limitations, the research question, ‘How do nursing students successfully
transition to graduate nurse?’, was answered. New knowledge has been created on the
subject of graduate nurse transition forming a unique and beneficial contribution to the body of
knowledge.
Recommendations
Implications for practice, organisational practice, and transition programs
Graduate nurses, in the same way as Cinderella, are especially vulnerable to self-neglect and
unfair treatment due to inexperience and their limited tenure. Graduate nurses need to feel
validated by their leadership and supported as individuals. Validation promotes acceptance by
members of the team and their preparedness to help graduate nurses succeed. Nurse
Managers need to be cognisant of these factors to avoid exploitation with the burden of over-
work, i.e., the expectation that graduate nurses will be constantly available to fill gaps in service
delivery. It is also recommended that the workplace support graduate nurses in their
professional and personal growth by keeping them informed of any organisational changes or
developments, providing access to further education, and access to resources within the
organisation. Each graduate nurse should be allocated a dedicated preceptor to work with
them on the same shifts. Preceptors also need education and allocation of time to enable them
to fulfil their teaching role. The effects of workplace incivility and horizontal violence from fellow
nurses and supervisors was frequently reported by graduate nurses as their most destructive
obstacle, and predisposed graduate nurses to mental ill health. Prevention of violence begins
with the attitude that experienced nurses have towards new nurses, who should be respected
and valued as important members of the health care team. Graduate nurses did not have a
fairy godmother to mentor them, and were found to be severely exposed during their first year
of practice, with mental health risks such as emotional fatigue, doubt, and cynicism ever
present. The need for counselling of graduate nurses and increased emotional support from
their nursing colleagues and inter-professionally is recommended. This includes provision of
copious amounts of quality feedback to mitigate possible graduate nurse distress. Nurse
administrators, transition program coordinators, and preceptors should be aware of these
concerns and have adequate educational preparation for their roles of support and guidance.
Implications for the nursing curriculum, clinical education, and preparation of
nursing students for the realities of transition
It is evident that many health care organisations do not provide consistent support, or any
support at all, for graduate nurses. It is therefore recommended that undergraduate nursing
programs prepare nursing students for transition in advance. There is an obligation to include
the psychosocial perspective in the university curriculum. This can be achieved in a number of
ways. The first is the issue of clinical experience, where there are reported gaps in nursing
students' responsibilities compared to those of the practicing registered nurse. These gaps need
to be closed so that nursing students are practicing the actual role of the registered nurse and
not a convenient version that fills in time. It is recommended that the research and knowledge
around the transition from nursing student to successful graduate nurse be encompassed in a
self-support model. There is a need to have a comprehensive self-support model for
undergraduate students, i.e., ‘ways of being’, which includes self-support, self-care, and self-
advocacy, in the nursing curriculum. Self-support, where embraced, is more reliable than a
transition program as it empowers and transforms the graduate nurse with skills that will
accompany them throughout their career and wherever they transition to in nursing.
Undergraduates need to be aware of the reality of transition and how to navigate the health care
culture. Teaching of communication skills that focus on relatedness and building of relationships
is important when adapting to stress and social acceptance. Such relationship building is
considered critical, and communication an essential facilitator of relatedness. Finally, emotional
intelligence, self-motivation, planfulness, and taking the initiative to seek help, were significant
strategies adopted by resilient graduate nurses in order to feel safe and not overwhelmed.
These self-support qualities need to be fostered in nursing students prior to graduation.
Further research into transition/graduate qualities
There are ways of being which have already been identified through this research; however, this
requires an ongoing process of discovery; a holistic and comprehensive expose on the
elements of transition that are challenging for graduate nurses. The first requirement is to
acknowledge the totality of the role of the graduate nurse. Many of the required learnings are
not called out, as stated earlier. For example, graduate nurses have been known to preceptor
and supervise nursing students in their first weeks of practice. Secondly, self-support and self-
care strategies have been recently assembled as a body of knowledge in the form of “ways of
being”. This initial assembly represents a beginning only, and further research is recommended.
In addition to interviews with graduate nurses and staff, inquiry inclusive of careful observational
studies in a variety of settings is required to ensure that current NMBA standards are a true
reflection of the contemporary role of the graduate nurse.
Conclusion
As stated in Chapter One, the purpose of this study was to generate further knowledge about
graduate nurses in transition. It was intentional for the aim to be flexible, thus allowing the
dynamic adoption of multiple methods, i.e., literature research, critical literature research, and
grounded theory methodology. These studies examined and interpreted the various
constructions that form the spectrum of factors and perceptions that have an impact on
graduate nurses and their passage to competent professional nurse in Australia from the
perspectives of graduates and the published research. The following research question
emerged: How do nursing students successfully transition to graduate nurse?
In Chapter Two, the contextual statement introduced the historical context, beliefs, and nurse
educational practices for over one hundred years - primarily from the perspective of health
services. Australian nurse education was a process of indoctrination with little change until 1984
when the national government made the decision to transfer registered nurse education to the
tertiary education sector. In the late 1980s, a position statement on transition programs for
graduate nurses was developed for South Australia. The support frameworks were based on the
transition theorists, Marlene Kramer and Patricia Benner, and the outcome of a number of
research reports and conferences. By 1993, they were a familiar discourse in many health
services. Despite the fact that the profession lauded these theories and recommendations, the
nature of clinical support provided for graduate nurses has not proven to be effective.
Overwhelmingly, it has been found that transition programs are primarily offered in order to
attract and recruit graduate nurses. There is minimal evidence to show they are effective in
assisting with transition. Graduate nurses have and continue to report bullying, incivility, and
lack of feedback or inappropriate feedback on their performance. Added to these concerns was
the lack of clarity with regard to education for the role of graduate nurse. The role is currently
not fully defined in terms of the comprehensive skill set required.
In Chapter Three, a contemporary integrative literature review, it was found that health care
organisations are primarily solipsistic and the likelihood of providing consistent quality support
or any support at all for graduate nurses is quite small. It was also revealed there was little
perspective from the university sector, or expectations of the university sector’s role in the
passage from student to competent professional nurse. Much of the literature around the
psychosocial factors involved was focused on postgraduate experiences of transition rather
than on purposive psychosocial preparation of nursing students for self-support. Universally,
transition to practice programs were reported as ineffective and, at times, harmful.
Chapter Four presented the five publications which, as an aggregate, demonstrate the
progression of theory by initially establishing the nature of support provided to graduate nurses
in publications one and two. These led to the consequential investigation of self-support in
publications three through to five. This chapter has synthesised the publications and clarified the
uniqueness of the penultimate research findings. The contribution of this research is the
development of new theory championing the transposition of thought towards a new reality and
research question, i.e., How do nursing students successfully transition to graduate nurse?
Such a self-support model is possible, as it has been found that graduate nurses can and do
self-initiate their own support because they cannot rely on formal transition programs. This
research has established that graduate nurses use multiple strategies to self-care, advocate for
themselves, and fit in to the ward culture. These have been quantified and developed in the
form of ‘ways of being’ and ‘spectrum of comfort’ considerations for the purpose of curriculum
development. Much of the literature has focused on postgraduate experiences of transition to
professional practice, rather than purposive psychosocial preparation of nursing students for
transition to professional practice. However, there should be the opportunity for undergraduate
student engagement in a self-support model facilitated by nurse teachers who are
knowledgeable about socio-emotional skills and the nature of transition and social interactions
which allow nursing students to imagine their success as graduate nurses. Furthermore, “ways
of relating” to more capable others during their transition year should be developed as a
consequence of these discussions. These preparatory activities create a virtual zone of
proximal development, as they arm nursing students with strategies to scaffold their effective
transition after graduation. This study has provided a unique perspective of graduate transition.
Emergent is the development of a distinctive and comprehensive preparation model with
resources that can be used to facilitate transition to professional practice. Indeed, the research
and knowledge around the transition from nursing student to successful graduate nurse can be
encompassed in a self-support model.
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