Running head: LITERATURE REVIEW

Literature Review on Factors Influencing Graduate Nurse’s Transition into Practice

Name of the Student

Name of the University

Author Note
LITERATURE REVIEW

Literature Review on Factors Influencing Graduate Nurse’s Transition into Practice

Nurses are one of the most important stakeholders in the health care system all across

the globe and have the greatest contribution to the total population of the health workforce.

With the increasing population, there is a significant need for increasing the count of nursing

professionals in health care settings.The new graduate nurses are the student nurse who have

just completed their bachelors or masters in nursing and have 6 months or less of experience

as paid registered nurse (Price et al., 2018).Prior to the transition to a more professional role

of a registered nurse, the student nurses and graduate nurses are given the experience of pre-

registration, which can be deemed as more familiar and comfortable for the student nurses.

However, transitioning to a professional role requires student nurses to acquire more

responsibilities with greater knowledge and relationships. The student nurses are confronted

with huge scope and range of sociocultural, developmental, emotional, intellectual, and, most

importantly, physical changes that may act as mitigating factors during the transition

(Silvestre et al., 2017). Such confrontation is marked with the term transition shock. The

following paper aim at conducting a narrative review of the literature determine the factors

that influence the transition of student nurses in professional practice settings and discuss the

factors elaborately along with main themes, such as transition shock and efficacy of clinical

placements. For the following narrative review of literature, no geographic limitations have

been applied to search for relevant literature.

Background

The transition into professional settings from an academic environment is challenging

for the new graduate student nurses. This is due to the thrust of transitioning between

personal and professional adjustments and alternate between the varying intensity &

fluctuating states of physical, sociocultural, intellectual, and emotional well-being

(Wakefield, 2018). The current knowledge on the topic is limited to the transition experiences
LITERATURE REVIEW

of the nurses to the contemporary environment. According to Ankers, Barton, and Parry

(2018), the first instance of transition shock was identified in the 1970s, where the new

nurses felt unprepared and overwhelmed by the demands of the clinical practice. Transition

shock is also referred to as reality shock, as this is the first experience of the student nurses

with the actual workload that their peers are used to, but seems to be greater than what the

student nurses have experienced till now. Such experiences require supervision and guidance

from experienced professionals, and the Nursing Professional Development (NPD)

practitioners execute this role by monitoring the conditions of the new registered nurses

(Wierman, 2016). The student nurses are enrolled with clinical placements or pre-registration

workplace experience, which helps them to get an insight into the workload and

environmental conditions of a registered (Kim & Yeo, 2019). Even though such simulations

have proved to be clinically effective in helping the student nurses gain valuable experience,

it is evident that clinical placements fail to offer a complete and real stimulation of work

experience for the student nurses. With the transition into clinical settings for the first time as

a registered nurse, the nurses have to accept a load of work responsibilities and roles, with a

new set of goals to handle a greater number of patients with multiple morbidities and

complex conditions. Such transitions get more difficult for the new nurses with the lack of

experienced coaches and mentors, a substantial increase in performance anxiety, the

incidence of bullying, and generational diversity in the nursing workforce. Other aspects to

take care of while transitioning from student nurse to registered nurse position are

expectations, change of role, blame, or support culture in the health care setting, working

atmosphere, knowledge, and workload. Ineffective strategies to cope with transitions have led

to an increase in the number of new nurses to quit their job, leading to a major issue of the

nursing shortage. Major stakeholders who are responsible for making the transitions easier

for the nurses include experienced professionals, nursing managers, and policymakers, who
LITERATURE REVIEW

can facilitate the transition process and help the nurses to cope with the consequences. The

negative consequences associated with transition shock include burnout danger, panic, fear,

tension, anxiety, and other endangers, which significantly increases when the higher

authorities fail to understand these changes and undermine the physical and mental health of

the nurses. The end results that may occur due to mismanagement of the consequences of

transition shock are job dissatisfaction, inability to fulfill responsibilities, poor job

motivation, projection, denial, fear, overdependence, and even isolation. The health outcomes

and safety of the patients are also endangered when the nursing individuals are facing such

issues, as such conditions may lead to the instance of medication errors.

Search Strategy

A search protocol is developed and followed to search for literature relevant to the

current research objective, which is to determine the factors that influence the new nurse’s

transition into clinical practice. The medical databases which were utilized to conduct the

search for literature will include PubMed Central, BioMed Central, and Cochrane Database

for Systematic Reviews. The use of specific keywords was ensured to increase the relevancy

of the search results, and the keywords were transition, new graduate nurse, student nurse,

transition shock, registered nurse, professional role, clinical practice, pre-registration, and

clinical placement. The use of Boolean operators was ensured to increase the count of

literature in the search results, and the two operators included ‘AND’ and ‘OR.’ The use of

the Boolean operator ‘AND’ was done to increase the count of literature in the search results,

and the use of operator ‘OR’ was done to refine the search and limit the results to include the

literature, which were highly relevant to the research topic. The advanced search option

available in the databases were used to include inclusion criteria, and only peer-reviewed

articles published in the last five years, that is, between 2016 and 2020, were selected for

final review. Other aspects of inclusion criteria include publishing language to be only
LITERATURE REVIEW

English, research articles concerned with the population of new graduate nurses only

irrespective of any age limits and research studies that conformed to the Level 1, 2, and 3 of

evidence, which includes systematic reviews, randomized control trials, and cohort studies.

Title and abstract review and analysis was performed to the articles in the search result to

generate a list of final papers. Out of the 236 research articles that were reviewed for abstract,

only six were marked for final selection, and full-text analysis was conducted for the selected

studies.

Results

Duchscher andWindey (2018) wrote an article to present the stages of transition and

transition shock in new nursing graduates. According to the researchers, the newly licensed

nurses are confronted with a great deal of sociocultural, developmental, emotional,

intellectual, and physical changes when engaging in professional practice for the first time.

One of the researcher Duchscher, developed a transition shock model in the year 2012, which

is evaluated in this paper to determine the contrast between responsibilities, roles,

relationships, performance, and knowledge of the new nurses when engaging in clinical

practice. The researchers highlight the initial 12 months post-transition to be very critical for

the new nurses and determine three stages of transition. The first stage, which is termed as

‘doing’ by the researchers, is the phase of transition shock, where the new graduate nurses are

confronted with learning, concealing, accommodating, adjusting, and performing

experiences. The second stage is ‘being,’ where the nurses perform actions of searching,

questioning, examining, revealing, and doubting, and this stage is part of a transition crisis.

The final stage of transition is ‘knowing,’ where the relatively experienced nurses post-

transition are involved in accepting, critiquing, exploring, recovering, and separating.

The researchers Hussein et al. (2016) conducted a cross-sectional study, which was

part of a larger prospective cohort study with the objective of determining the predictor of
LITERATURE REVIEW

satisfaction of the new graduate nurses with the transitional support program and evaluating

the efficacy of clinical supervision in supporting the program. He researchers used MCSS-26

and PES-AUS scales to measure the satisfaction level of the new graduate nurses with their

transitional support program. The sample size was of 109 new graduate nurses ranging from

age 20 to 53 years, and three-fourth of the sample were female. The median of the

satisfaction score from the study stood out to be 7. However, the score ratings regarding the

confidence of new graduate nurses to handle critical situations ranged from 2 to 5, with a

median of 4. This highlights the insignificance between levels of satisfaction and levels of

confidence among the new graduate nurses.

The researchers Rush et al. (2019) conducted an integrative review to determine the

most adequate practices for the transition programs concerned with the new graduate nurses.

The research findings from the review of the literature suggest that health care organisations

thrive for low turnover rates and higher retention rates for the new graduate nurses. One of

the key highlights from the transition program was peer support opportunities, which helped

the new graduate nurses to discuss their transition experiences with their peers. Furthermore,

mentorship programs were deemed to be a positive influencer to nurse’s satisfaction levels

and help to reduce their stress.

The researchers Thomas and Mraz (2017) conducted a research study based on

descriptive phenomenological methodology and study design to explore the efficacy of

simulation and determine how it affected the clinical practice of the new graduate nurses.

According to the research findings, six themes were identified, which included responsibility

for independent practice, seeing the big-picture of client care, theory to practice clinical

problem solving, communication with peers and patients, and confidence. According to the

authors, simulation experiences for the new graduate nurses provides immense support to
LITERATURE REVIEW

their confidence, reflection, communication, and decision-making skills, and help them

undertake professional roles and responsibilities in clinical settings.

The researchers Murray, Sundin, and Cope (2018) conducted a study with the aim of

evaluating the Duchscher's theory and Benner's model to deliver a framework for greater

understanding of the new nursing individual’s transition to clinical practice. The researchers

explore the Benner’s model of skill acquisition from novice to expert, where the novice

characteristics include no experience in a clinical situation, and the expert characteristic

includes an intuitive grasp of each clinical situation. The intermediate levels between novice

and expert include advanced beginner, competent, and proficient. The researchers also

evaluate the transition stages model by Duchscher, which includes intercepts at the

orientation phase, 3-month transition shock, 6-months transition crisis, and the final interview

for data collection. One of the greatest implications for nursing with a better understanding of

these two models and theory is that the experienced nurses and other experienced

professionals can provide transitional support to the new graduate nurses in stages, which will

help them adjust to the professional life with greater ease.

Another study conducted byHussein et al. (2017) aimed at exploring the perception of

the new graduate nurses regarding the transitional support provided to them in clinical

specialty. The researchers used a mixed-method study design, which included a prospective

survey. Qualitative data were collected with the help of an open-ended questionnaire and

quantitative data with the help of a close-ended questionnaire, from which descriptive and

inferential statistics were used to perform content analysis. The primary highlight of the

negative responses wasassociated with a mismatch in the level of support given versus

expectation and increasing workload. Developing clinical competence and orientation for

transitional support program were deemed as a foundation of success.

LITERATURE REVIEW

Discussion

Implications for Nursing

The analysis of the aforementioned research studies highlights the importance of

providing transitional support to the new graduate nurses at the initial stages to help them get

off to a good start, with greater confidence and eagerness to adjust to professional

requirements. Undergrad training recognizes Benner's phases of ability procurement by

showing nursing aptitudes in stages all through a multi-year baccalaureate degree, getting

ready nursing understudies as cutting edge apprentices upon graduation. For nurture

instructors, tutors, and pioneers in the work environment, recognizing and understanding

Benner's phases of ability obtaining and Duchscher's phases of progress hypothesis and

change stun model can serve to improve the new graduate nurse's progress to rehearse

through experience. This will aid the foundation of persistent valueas well-being rehearses

through focused instruction and tutoring, and sensible desires for capability and experiential

ability obtaining in the primary year of clinical practice (Kim, Yeo& Yi, 2017).

This will similarly have a positive effect onthe maintenance of the new alumni.

Weakening is expensive for well-being administrations, prompting nursing deficiencies, and

at last, affecting the well-being of the patient (Phillips et al., 2014).

Transitional Support Program

The transitional support programs are evident to be providing opportunities to the new

graduate nurses to help them develop clinical competence. During the first rotational phase

into clinical settings, the new graduate nurses require a substantial amount of peer and

instrumental support, to help them adjust with the rest of the workforce. The key stakeholders

that are important in delivering the comprehensive orientation program and peer support to

the new nurses include nurse educators, unit managers, experienced registered nurses, and

clinical nurse specialists.

LITERATURE REVIEW

Skill Acquisition

Communication skills are one of the most vital skills required in professional practice.

In addition, this building clinical competence can significantly help the new graduate nurses

to undertake the professional role and responsibilities with greater ease (Innes&Calleja,

2018). Adequate skill mix and becoming the part of the team is essential for smoother

transitions. The nursing educators and unit managers play a critical role in ensuring proper

workload for the new graduate nurses and prevent emotional, mental and physical burnout of

the individuals, to increase the retention rates and lower the turnover rates.

Simulation Programs

Prior to joining a professional workplace and workforce, the student and graduate

nurses are often enrolled with pre-registration experience programs and clinical placements to

help them get an overview of the conditions and responsibilities when they will be sent to

clinical settings. Such programs are highly efficient in delivering real-life simulation

scenarios to graduate nurses. Such stimulation programs, along with debriefing conferences,

are of great use in assisting the nurses to integrate their theoretical knowledge with clinical

practice and developing essential skills of critical thinking, problem solving, and decision-

making (Adler et al., 2018). Moreover, clinical placements and their undertaken stimulation

programs, along with debriefing conferences, ease the transition hardships experienced by the

new graduate nurses and help them attain professional growth even before they join clinical

settings for professional practice (Palmer& Ham, 2017).

Conclusion

The above sections of the paper provide information on the literature review

conducted on the topic of factors influencing the transition of new graduate nurses to

professional practice in clinical settings. Transitional shocks are the condition in which the

new graduate nurses find it difficult to adjust to the professional lifestyle and are in high need
LITERATURE REVIEW

of physical, emotional, and social support from the peers to help adjust to professional

practice. It is revealed that clinical placements and pre-registration programs provide

immense experience to the new graduate nurses and aids them in integrating their nursing

knowledge in real-life nursing situations. In addition to this, the experienced professionals

and nursing educators need to undertake orientation and transitional support programs to help

new nurses integrate better with the existing workforce. Ensuring the successful transition of

the new graduate nurses refers to the acceptance of the professional roles and responsibilities

by such new individuals and requires a competent workforce to provide transitional support.
LITERATURE REVIEW

References

Adler, M. D., Mobley, B. L., Eppich, W. J., Lappe, M., Green, M., &Mangold, K. (2018).

Use of simulation to test systems and prepare staff for a new hospital

transition. Journal of patient safety, 14(3), 143-147.10.1097/PTS.0000000000000184

Ankers, M. D., Barton, C. A., & Parry, Y. K. (2018). A phenomenological exploration of

graduate nurse transition to professional practice within a transition to practice

program. Collegian, 25(3), 319-325. https://doi.org/10.1016/j.colegn.2017.09.002

Duchscher, J. B., &Windey, M. (2018). Stages of transition and transition shock. Journal for

nurses in professional development, 34(4), 228-232.

10.1097/NND.0000000000000461

Dwyer, P. A., &Revell, S. M. H. (2016). Multilevel influences on new graduate nurse

transition: A literature review. Journal for Nurses in Professional

Development, 32(3), 112-121. 10.1097/NND.0000000000000265

Hussein, R., Everett, B., Hu, W., Smith, A., Thornton, A., Chang, S., &Salamonson, Y.

(2016). Predictors of new graduate nurses’ satisfaction with their transitional support

programme. Journal of nursing management, 24(3), 319-326. 10.1111/jonm.12321

Hussein, R., Everett, B., Ramjan, L. M., Hu, W., &Salamonson, Y. (2017). New graduate

nurses’ experiences in a clinical specialty: a follow up study of newcomer perceptions

of transitional support. BMC nursing, 16(1), 42. 10.1186/s12912-017-0236-0

Innes, T., &Calleja, P. (2018). Transition support for new graduate and novice nurses in

critical care settings: An integrative review of the literature. Nurse education in

practice, 30, 62-72.https://doi.org/10.1016/j.nepr.2018.03.001

Price, S. L., Hall, L. M., Murphy, G. T., & Pierce, B. (2018). Evolving career choice

narratives of new graduate nurses. Nurse education in practice, 28,

86-91.https://doi.org/10.1016/j.nepr.2017.10.007
LITERATURE REVIEW

Kim, E. Y., & Yeo, J. H. (2019). Effects of pre-graduation characteristics and working

environments on transition shock of newly graduated nurses: A longitudinal

study. Nurse education today, 78, 32-36.https://doi.org/10.1016/j.nedt.2019.04.002

Kim, E. Y., Yeo, J. H., & Yi, K. I. (2017). Development of the Transition Shock Scale for

newly graduated nurses. Journal of Korean Academy of Nursing, 47(5), 589-

599.https://doi.org/10.4040/jkan.2017.47.5.589

Murray, M., Sundin, D., & Cope, V. (2019). Benner's model and Duchscher's theory:

Providing the framework for understanding new graduate nurses' transition to

practice. Nurse education in practice, 34, 199-203.

https://doi.org/10.1016/j.nepr.2018.12.003

Palmer, B. J., & Ham, K. (2017). Collaborative simulation: Enhancing the transition to

clinical practice. Nursing education perspectives, 38(5), 281-

282.10.1097/01.NEP.0000000000000166

Phillips, C., Kenny, A., Esterman, A., 2017. Supporting graduate nurse transition to practice

through a quality assurance feedback loop. Nurse Educ. Pract. 27, 121–127.

https://doi.org/10.1016/j.nepr.2017.09.003.

Rush, K. L., Janke, R., Duchscher, J., Phillips, R., & Kaur, S. (2019). Best practices of formal

new graduate transition programs: An integrative review. International journal of

nursing studies. 10.1016/j.ijnurstu.2019.02.010

Silvestre, J. H., Ulrich, B. T., Johnson, T., Spector, N., &Blegen, M. A. (2017). A multisite

study on a new graduate registered nurse transition to practice program: Return on

investment. Nursing Economics, 35(3), 110.https://ncsbn.org/out.pdf

Thomas, C. M., &Mraz, M. A. (2017). Exploration into how simulation can effect new

graduate transition. Clinical Simulation in Nursing, 13(10), 465-470.

http://dx.doi.org/10.1016/j.ecns.2017.05.013.
LITERATURE REVIEW

Wakefield, E. (2018). Is your graduate nurse suffering from transition shock?. Journal of

Perioperative Nursing, 31(1),

47.https://search.informit.com.au/documentSummary;dn=474537270039300;res=IEL

HEA

Wierman, M. G. (2016). Effects of trained preceptors on new graduate nurses’ transition to

practice: An integrative literature review.https://digitalcommons.stritch.edu/etd/501