Introduction

From the last few years, the continuous decrease in the nursing workforce has been noticed by experts when compared with the total number of patients. This considerable fall in the number indicates the inability of the new nursing graduates. If further examined, this situation speaks a lot about the process a nursing student has to go through to become a professional nurse. The lack of professional nurses has turned into a major global concern. Thus, it is relevant to investigate the insights and possible theories to put the light on the transition process from a native student to professional nurse. There are barriers a student face during his or her journey to become a professional these factors affect their coping ability and strategies they use to survive during the transition process.

Stages of Transition

Patrica Banner the famous nursing researcher and the writer of the book “Novice to Expert” has formed a theory on the basis of the evidence she has gathered in the form of information received by directing overviews on the new graduate nurses.  Banner has met numerous nurse practitioner over a period of 20 years to really understand the major concepts of transition factors, barriers, techniques, etc. In her theory, Banner explained the five main stages of the nurse transition which are the new graduate, advanced beginners, competent, proficient and expert (Benner, 1984). Here, Novice refers to the native who comes up with the learning capacity and lacks proficiency, knowledge and experience required to perform a task. They do not possess enough knowledge of drugs, laboratory tests and their results, pharmacology, and different surgeries. Apart from this, they also lack practical experience in using medical equipment, inserting an intravenous drip, and other ventilator devices. An advanced beginner has to face several situations that are involved in the patient care process both directly and under the supervision of the senior nurse. During this stage, nurses start gaining the required knowledge and experience to efficiently perform patient related activities. Competent nurses are capable enough to the problem of the patients and start providing appropriate care accordingly. They can almost picture the patient’s condition and any other clinical scenarios and provide the right care with confidence. Proficient nursing, on the other hand, uses their experience to make critical medical decisions regarding patient care. It requires proper knowledge and years of experience which only can be earned by monitoring the clinical cases to get on this stage. Nursing professionals can provide care to patients despite the guidelines, solely depending on their clinical experience. It requires lots of time and hard work to get on this stage and not all professional nurses can become experts even after their gaining years of experience in the field. Nurses at this stages usually involve in major tasks like leadership, delegation, and decision-making process. (Benner, 1984).

Problems Faced by New Graduate Nurses During Transition to Employment

The latest research has highlighted some of the major problems faced by the new graduate nurses during the final year of their professional studies.  (Missen et al., 2014; Sonmez & Yildirim, 2016). The listed barriers below covers both internal and external factors.

1. Lack of practical knowledge and clinical expertise

The process of handling real-life situations could be quite difficult for the new graduates. Majority of the nurses feels there is a huge difference between the knowledge they have earned during their graduate studies and practical expertise. Most of them often feel that they lack the knowledge required to become a nurse. Missen et al. (2014) studied a group of graduate nurses and their perceptions to find out more about the common issues faced by newly graduates. Most of them believed that during their first 4 to 6 months of employment they have a conflict of thought about their career due to the high stress, heavy workloads and rotational shifts. Sonmez & Yildirim (2016) has further examined this and find out that main reason behind the difficulties faced by the new graduate nurses is lack of subject knowledge and expertise which required to perform patient care activities. Nurses who had participated in the survey have informed due to their lack proper knowledge of main drugs, pharmacology and different laboratory tests, their interpretations and surgeries they had to face complicated issues. They also mentioned that they lacked expertise in inserting drips, handling medical equipment and ventilator devices.

2. Less than ideal communication

The main component of successful patient care is communication as people says “communication is the key”. The excellent communication is necessary for the free flow of ideas, division of work pressure and the sharing of knowledge. Poor or lack of communications between the team members often leads toward the confusion and poorer outcomes. The possible outcome includes emotional burnout, stress and lack of encouragement to carry forward. These negative outcomes can make a huge impact on the new graduate nurses making themselves for the choice of career, lack of knowledge, clinical expertise, etc. The major barrier that can be seen in the new graduate nurses and physicians is because of the lack of confidence (Pfaff et al., 2014).

3. Heavy workload

Sonmez & Yildirim (2016) highlighted that heavy workload is another main challenge faced by the new graduates during their first 6 months of employment. The heavy workload could be due to the shortage of nurses or high rate of patients that need medical attention. In another study, it was shown that how heavy workload can be made a negative effect on the personal lives of the new graduate nurses endangering the balance between personal and professional life. Because of the shortage of the staff, many nurses had to work in rotational shifts even on the weekends and without a relevant break to take some rest. This can further bring more problems in their personal relationship putting more stress on the nurses making them question their choice of career or profession.

4. Reality shock

The coordinator of the new nurses has explained that majority of the nurses have high expectation with their role as a nurse. They enter the profession to help those who need medical attention. Not after a long time, they start comparing themselves with the senior nurses and feel they should start providing patient care similar to them. During this process, due to their high expectation with their job and lack of clinical expertise, they face several resentments.

Role Stress and Ambiguity

This is a situation which arises due to increased demand for performance and diffuse responsibilities. The students are not fully aware of their roles and responsibilities. The emotional burnout results when there is an expectation of expansion of knowledge and skills.

Factors Affecting the Coping of New Graduate Nurses to Transition

Previously mentioned problems and issues were faced by the new graduate nurses due to their lack of knowledge and practical expertise to the transition. Therefore, addressing and resolving these issues can improve the coping ability of the graduates and improve the quality of patient care. Azimian et al. (2014) had pointed out the following factors that will positively affect and improve the coping ability of new graduates during the transition phase.

1. Training and development programs

Kaihlanen et al. (2013) identified that teacher or mentor is the main source from where graduates receive clinical experience in order to complete the transition. University education provides theoretical knowledge to students regarding clinical practices. The education program medical university follows should include professional practices to prepare them for the future. (Azimian et al., 2014) even after joining the employment, hospitals must provide training to graduate nurses on the instant base for at least 2 to 3 months. The regular training sessions should be conducted on regular basis to keep them educated and up-to-date with the present practices.

2. Horizontal violence

Dyess & Sherman (2009) mentioned horizontal violence is not a new thing in the nursing field. But the rate is higher in the new graduate nurses which could be considered as a major factor that inferring with coping. Horizontal violence is a sort of aggression one receives from the colleague, it could be either physical or emotional. Laschinger & Fida (2014) highlighted that new graduate nurses face the greatest risk in comparison to advanced beginners and competent. It is so common in the nursing field that most of the time it goes vastly unacknowledged. The positive work environment, healthy leadership and work satisfaction play vital roles in the transition to employment during the first 6 months of employment.

3. Professional isolation

New graduates face many situations when they perceived being alone in their situation and these experiences affected them adversely. Rush et al. (2013) studied that new nurses require formal support from the senior nurses who have successfully completed their 9 to 12 months in employment. The professional support from the physicians, senior nurses and mentors help new graduate nurses to further cope with their transition phase. Along with the professional support, personal support from the friends and family also proven to help nurses to deal with the transition (Azimian et al., 2014).

4. Collaboration of different healthcare professionals

Lack of communication between the team members including new nurses can lead toward the fatal outcomes. All the negative outcomes student nurses witness during their first year of employment can make a huge impact on them, making them question their knowledge and ability. Therefore, it is crucial to establish an effective communication with other colleagues, physician, and experienced nurses as it helps to cope with the transition. The process of effective communication does not only help student nurses to develop a strong bond with their fellow colleagues but further opens the doors for knowledge sharing, teaching and clinical expertise. Through communication, student nurses can involve in the decision making processes. All these factors boost the confidence of the new graduates which will improve their coping ability.

5. Professional commitment

Azimian et al. (2014) established that apart from the fundamental support at all the level and training programs being responsible and in charge of their job likewise helps student nurses in adapting to change. This requires proficient responsibility and commitment from their site along patient-focused methodology. The commitment they make further encourage them for the self-learning process.

6. Shortage of workforce

Sonmez & Yildirim (2016) mentioned in their investigation that workload on the nurses is constantly increasing due to the shortage of the workforce was one of the real obstructions for adapting the transition in the new nurses during the first year of employment. If you closely examine the overall ratio of the nurse and patient then, you may find that there is only one nurse over six patients which is greater than recommended. Heavy workloads can also make negative impacts on the personal lives of the nurse graduates and affecting their adapting to the change.

7. Personal traits

Certain factors which have a positive impact on the coping ability of new graduates are tuning themselves according to the expectations of others, using their knowledge gained during education in the present role, leaving behind the negative attitudes, alteration of their communication ways and being creative and innovative in their present scenario.

8. Physical and emotional well being

It is important to stay fit and healthy and perform a job in the best way possible. Therefore, the physical and emotional well-being of the nurses affects the coping ability in a positive manner. Physical well-being helps in coping with the heavy workload and more number of shift hours. Emotional well-being helps in building self-image in the process of transition. (Azimian et al., 2014).

Strategies to Improve New Graduate Nurses’ Coping to Transition Into Employment

1. Incorporating inter-professional practice

It The collaboration practice takes place when various healthcare professionals work with individuals within their profession along with other members outside of their profession with caregivers. Such incorporations are a great way to share knowledge in inter-professional practice system. A healthcare team basically involves professional experienced nurses, physicians, medical caregiver, and new nurses (Mitchell et al., 2012) while taking a crucial decision-making every one of the individuals is equally involved. Hence, it help new students to discover different medical situations under the supervision of professional and experienced group of doctors and master nursing experts.  (Kilpatrick et al., 2014) This procedure gives an opportunity to the new graduate nurses to learn with experienced professionals while expressing their feeling regarding the clinical decisions side by side. It also cut down the heavy workload on the nurses and boost their self-confidence. Thus, this practice more or less cut down the physical and emotional distress of the student nurses.

The adaptation and implementation of the practice help to improve the knowledge, skills and experience of the new graduate nurses as they can participate in the decision-making process along with the experienced professionals such as doctors, caregivers, and senior nurses.

Implementation of residency programs

Al Dossary et al. (2014) underlined that learning nurses need residency programs on an urgent basis to transform into an advanced or competent nurse. These programs must involve practical training that is related to their fields, education or knowledge can improve the decision-making process of the new graduates. Along with this, these programs can help to improve the leadership and decision making skills. In return, help them cope with the transition process and move ahead and secure the position of the competent nurse.

Effective leadership or mentorship

There is various leadership style used by several large-scale corporations around the world but when it comes to the nursing, there are about three types of leadership styles that can be adopted by the experienced nurses to train the new nurses who lack both knowledge and experience in the field. These three styles are known as democratic, autocratic, and laissez free styles. Democratic leadership is also known as participative leadership is a shared type of leadership where important decisions are taken by the members of the team. This is the reason why it is known as participative leadership. The adoption and implementation of these leadership styles can help new nurses to overcome the barriers and challenges of the transition phrases like lack of knowledge, poor communication, lack of expertise, etc. (Martindale 2011).

2. Exhibiting resilience

Graduate nurses may encounter different stress factors during the transition. The barriers such as lack of knowledge and clinical expertise, poor communication, role stressors, the ambiguity of roles and responsibilities, etc. cause physical weakness and emotional burnout. Therefore, it is suggested that all the new nurses go with some resilience strategies to fight back with the emotional and physical burnout and further cope with the new role. (McCann et al., 2013)

A study conducted on nine nurse practitioners studied the factors contributing to resilience in them. These factors include acquiring sufficient knowledge and clinical expertise, positive attitude towards the conditions, work satisfaction, inter-professional communication, coordination and collaboration with other health care professionals, and maintaining the balance between personal life and work.

CONCLUSION

The decrease in the number of nurses we have noticed above may be related to the lack of ability of new graduates to cope with the transition phrase which is necessary to become a professional nurse. The limitation of the nursing workforce has become a matter of global concern. Therefore, it is necessary to explore the possible theories and barriers who highlights the challenge of the transition process to become a professional nurse. The process could be stressful for many beginners who do not possess enough knowledge and experience in the field. There are many issues such as the lack of clinical expertise, communication skills, heavy workloads and unrealistic expectations that are faced by the new nurses during their first year of employment. All these factors emerge like a barrier and can negatively affect the coping ability, well-being, and commitment of the student nurses. This will leave behind the bad attitudes, decrease in the nursing workforce and workplace environment. There are several strategies that can be used to help new nurses to overcome the potential barriers. Implementation of these strategies can leave a positive impact on the new graduate nurses and improve the quality of the patient care.