Research shows the transition from student to newly qualified nurse is a reality shock
In this article…
- How newly qualified nurses feel about their transition from student to staff nurse
- Gaps in the knowledge of newly qualified nurses
- Common themes emerging from a review of the literature on this subject
Bill Whitehead is senior lecturer, University of Derby; Dinah Holmes is community staff nurse, NHS Derby City.
Whitehead B, Holmes D (2011) Are newly qualified nurses prepared for practice? Nursing Times; 107: 19/20, 20-23.
Background While many people find starting a new job stressful, the transition from student to newly qualified nurse comes with additional pressures, as being unprepared could harm patients.
Aim To investigate whether newly qualified nurses in the UK feel prepared for practice, exploring their experiences and expectations as they make the transition from student to registered practitioner.
Method A review of the literature was carried out to look at newly qualified nurses’ experiences of becoming staff nurses within adult nursing, and to identify if there were gaps in that body of knowledge that could be addressed to support them.
Results There is still a significant gap between theory and practice and ward managers’ expectations of newly qualified nurses can be unrealistic. Some newly qualified nurses learnt to cope with being “thrown in at the deep end” but this is not always the best way of making the transition to becoming a staff nurse. The pressures of a busy ward environment means that soon-to-be qualified students are being treated as part of the workforce, and their learning needs are not a priority.
Conclusion Introducing a mandatory preceptorship programme would assist in smoothing the transition from student to staff nurse.
Making the transition from student to qualified nurse is a stressful experience. Literature on the issue indicates this is not confined to the UK but transcends international boundaries (Morrow, 2009; Pellico et al, 2009; Kelly and Ahern, 2008).
Nor is this a new concept - Kramer (1974) wrote about “reality shock” to describe the difficulties newly qualified nurses had in preparing for their role. This important work carried out in the US was revolutionary in that it identified the thoughts and feelings of newly qualified nurses, and has been a focal point in many subsequent studies.
The government publication A High Quality Workforce outlined how healthcare organisations such as the NHS should improve the quality of their services for their staff (Department of Health, 2008). Its recommendations included improvements to nursing education, preceptorship and continued professional learning.
Higgins et al (2009) identify these new recruits as not only the future but also the here and now for healthcare, given that nearly 60% of the nursing workforce is newly qualified. Consequently, the transition from student to qualified nurse should be a major concern for the NHS and nurse managers.
Ford (2009) reported the Nursing and Midwifery Council (NMC) was finalising the standards for a year-long preceptorship programme for newly qualified nurses in line with the Department of Health’s preceptorship framework, which is now in place (DH, 2010). Following the Darzi review (DH, 2008), preceptorship is fully funded by central NHS funds amounting to £30m per year (Keen, 2010).
But, in line with its shift to localism, the government appears to be retreating from its commitment to nationally guaranteed preceptorship in favour of leaving it to the NMC to legislate or for local employers to make the decision themselves (Corbett, 2011).
In our search we focused on articles that captured newly qualified nurses’ experiences about their transition from student to staff nurse within adult nursing. The search for articles was limited to those published after Kramer (1974) because we felt this seminal study had set a precedent. Geographically, the search was limited to in the UK so we would collect data most in line with local nurses’ experiences.
We systematically searched the CINAHL, Medline, Science Direct and British Nursing Index (BNI) databases for literature. This generated 37 articles, 33 of which were rejected because they were outside the review parameters or not research articles. We also looked at reference lists from the articles and this provided three more papers.
A total of seven were included in the review (Mooney, 2007; Ross and Clifford, 2002; Whitehead, 2001; Gerrish, 2000; Baillie, 1999; Maben and McLeod Clark, 1998; Jasper, 1996). These are summarised in Table 1.
Various themes emerged from our analysis: transition and preparation; accountability and responsibility; support; and learning to cope.
Transition and preparation
Baillie (1999) identified this transition as inevitable and uncontrollable and said nurses found the experience particularly overwhelming, with participants experiencing feelings of heightened stress.
Jasper (1996) discussed the transition of the students to nurses as moving between two different worlds, suggesting that of the student was sheltered, whereas the world of the newly qualified was exposed. Whitehead (2001) identified problems with trepidation and fear and Maben and McLeod Clark (1998) noted newly qualified nurses felt “on their own” compared with being a student and expressed their experiences as “highs” and “lows”. Participants included the positive aspects of the role, which they consistently articulated, rather than focusing purely on the negative aspects of the transition.
These findings highlight the idealism of what is being taught during nurse education programmes and compare this to the reality of practising as newly qualified nurses within the constraints of resources and local policies. This implies there is still a significant gap between theory and practice.
Whitehead (2001) suggested this issue should be seriously considered by those directly involved in nurse education. Her findings identify concerns about the preparation of newly qualified nurses from day one, regardless of any support packages that may or may not be in place.
Mooney (2007) noted that the participants in her study felt there was no time for nursing, suggesting the time spent as students did not prepare them for the realities of practice. Her study found that other staff and patients had high expectations of newly qualified nurses once they were in practice, along with an assumption that qualified meant “all knowledgeable”.
Accountability and responsibility
The increase in newly qualified nurses’ responsibility and accountability was a major stressor in the transition process in all the papers we reviewed. Responsibilities can be subdivided into: management; delegation; drug administration; and prioritising.
From her qualitative active research study of student nurses, newly qualified nurses and ward managers, Baillie (1999) identified management skills of newly qualifieds as a major area of concern.
Mooney (2007) highlighted how ward managers’ expectations of newly qualified nurses were unrealistic, suggesting that pressures of the ward environment, being able to adapt and integrate quickly, and the added responsibility of accountability were particularly overwhelming.
Maben and McLeod Clark (1998) also noted inconsistencies in preparation for management, suggesting that while the theoretical context was adequate, the practical aspects, such as drug administration, prioritising, decision making and clinical skills were variable. This was attributed to the differences each practice placement offered the participant, so varying their individual experiences and abilities.
Gerrish (2000) identified managerial responsibilities for the newly qualified as problematic; this related to both self-management and management within a team. Despite the exposure to practical placements as part of the training curriculum, it was only when working as a qualified nurse that the realities of what was required became apparent. Mooney (2007) suggested these negative experiences had a profound influence on whether newly qualified nurses remained in the profession.
A major cause of anxiety during the transition was drug administration (Maben and McLeod Clark, 1998). Before qualifying, student nurses had carried this procedure out only under rigorous supervision but were expected to practise unsupervised following qualification. These concerns suggest this area of practice is not adequately addressed during the education and preparation of nurses (Mooney, 2007; Ross and Clifford, 2002; Whitehead, 2001).
Jasper (1996) suggested that, despite an obvious lack of support, newly qualified nurses learnt to cope with the change in status from supernumerary student to independent practitioner as an aspect of their new role, which resulted in their confidence levels increasing.
The environment where newly qualified nurses first work is crucial to a smooth transition. The majority of newly qualified nurses experienced a lack of support (Mooney, 2007; Whitehead, 2001).
A period of preceptorship has been recommended during the transition (NMC 2006), although evidence suggests practice is variable.
Whitehead (2001) found staff shortages were a major contributor to the lack of support given to newly qualified nurses once in post, rather than unwillingness from established members of staff. This should be a concern for ward managers who decide what constitutes adequate staffing levels, as this will directly affect the policy of a mandatory preceptorship programme.
Ross and Clifford (2002) and Baillie (1999) identified that, due to pressures of a busy ward environment, soon-to-be qualified students said they were treated as part of the workforce and their learning needs were not a priority. These negative experiences exacerbated their feelings of stress and affected their perceptions of qualification.
This was reflected in studies by Mooney (2007) and Maben and McLeod Clark (1998), which said preceptorships were beneficial because they eased transition. These findings are consistent with international literature (Morrow, 2009; Pellico et al, 2009; Kelly and Ahern, 2008).
The challenge is how to improve these circumstances for future newly qualified nurses. Whitehead (2009) recommended that a clinical supervisor should be available full time to support and give guidance to newly qualified nurses while on shift. This could alleviate much of the anxiety felt by these nurses as they could seek advice at any time without putting extra pressure on other staff.
As a direct result of not feeling adequately supported, some newly qualified nurses learnt to cope with being “thrown in at the deep end”; this in itself was often a significant turning point for them, helping them to develop their analytical skills and boost their confidence (Maben and McLeod Clark, 1998).
This approach was not always seen as positive. Ross and Clifford (2002) and Whitehead (2001) reported that some newly qualified nurses were left in a situation where they had to cope rather than being taught. However, it could be argued that they were able to survive the transition through their own strength of character, not necessarily because of appropriate preparation.
The literature described several common themes suggesting newly qualified nurses did not feel adequately prepared for their roles in practice.
Small-scale research has limitations so we were cautious when attempting to generalise, but the themes from the literature of approximately 200 participants suggested common experiences shared by newly qualified nurses.
These findings should be considered by nurse educationalists preparing students for registration. More importantly, the findings should be taken into account by those employing newly qualified nurses when designing preceptorship programmes to support their transition from student to staff nurse.
Ross and Clifford (2002) found participants suggested specific changes to the way clinical placements were selected during nurse training that could potentially be useful to nurse educationalists. They suggest allowing students to choose their final placement area would have been particularly beneficial, especially if it was an area in which they wanted to work once qualified. Adopting this system could better prepare them for the role and identify their learning needs before the final transition to becoming newly qualified nurses.
Introducing a mandatory preceptorship programme would assist with a smoother transition and we recommend this long-awaited modification, after which further research is essential to assess its effectiveness.
5 key points
- Making the transition from student to qualified nurse is stressful
- Ensuring a smooth transition should be a concern for the NHS and nurse managers
- Healthcare organisations can improve services with better nurse education and continued professional learning
- For some newly qualified nurses, being thrown in at the deep end can help them to develop their analytical skills and boost confidence
- Introducing a mandatory preceptorship programme would offer support to newly qualified nurses
Baillie L (1999) Preparing adult branch students for their management role as staff nurses: an action research project. Journal of Nursing Management; 7: 225-234.
Corbett E (2011) Response to Your Query: Ref: DE00000558770 - Funding for the Preceptorship of Newly Qualified Nurses. Email from DHMail@dh.gsi.gov.uk to Bill Whitehead, 23 November 2011.
Department of Health (2010) Preceptorship Framework for Newly Registered Nurses, Midwives and Allied Health Professionals. London: DH. tinyurl.com/preceptorship-framework
Department of Health (2008) A High Quality Workforce. NHS Next Stage Review. London: DH. tinyurl.com/the-next-stage-review
Ford S (2009) Research highlights risk of low nursing numbers. Nursing Times; 105: 12, 8-10.
Gerrish K (2000) Still fumbling along? A comparative study of the newly qualified nurse’s perception of the transition from student to qualified nurse. Journal of Advanced Nursing; 32: 2, 473-480.
Higgins G et al (2009) A systematic review of the experiences and perceptions of the newly qualified nurse in the United Kingdom. Nurse Education Today; 30: 6, 499-508.
Jasper M (1996) The first year as a staff nurse: the experiences of a first cohort of Project 2000 nurses in a demonstration district. Journal of Advanced Nursing; 24: 4, 779-790.
Keen A (2010) Nurses: training. Hansard; 10 March 2009: column 387W. tinyurl.com/nurses-training-hansard
Kelly J, Ahern K (2008) Preparing nurses for practice: a phenomenological study of the new graduate in Australia. Journal of Clinical Nursing; 18: 910-918.
Kramer M (1974) Reality Shock: Why Nurses Leave Nursing. St Louis: CV Mosby.
Maben J, Macleod Clark J (1998) Project 2000 diplomates’ perceptions of their experiences of transition from student to staff nurse. Journal of Clinical Nursing; 7: 2, 145-153.
Mooney M (2007) Facing registration: the expectations and the unexpected. Nurse Education Today; 27: 8, 840-847.
Morrow S (2009) New graduate transitions: leaving the nest, joining the flight. Journal of Nursing Management; 17: 278-287.
Nursing and Midwifery Council (2006) Preceptorship Guidelines. NMC Circular 21/2006; tinyurl.com/nmc-circular-2021
Pellico LH et al (2009) What newly licensed registered nurses have to say about their first experiences. Nursing Outlook; 57: 4, 194-203.
Ross H, Clifford K (2002) Research as a catalyst for change: the transition from student to registered nurse. Journal of Clinical Nursing; 11: 4, 545-553.
Whitehead J (2001) Newly qualified staff nurses’ perceptions of the role transition. British Journal of Nursing; 10: 5, 330-339.
Whitehead W (2009) An Investigation into the Effects of Clinical Facilitator Nurses on Medical Wards. Unpublished PhD thesis, University of Nottingham.