transition to practice nursing essay

How Nurse Leaders Can Support New Nurses’ Transition Into Practice

• New nursing graduates transition from academia to clinical practice, entering a rapidly changing and demanding workplace.
• Quality transition to practice programs are linked to higher staff retention and job satisfaction, lower reported error rate, and better quality nursing care.
• Nurse leaders can help promote the investment in (and implementation of) quality transition-to-practice programs that improve outcomes and lower costs.

Nursing graduates are entering a rapidly changing and demanding environment with patients that have complex needs and larger patient-to-nurse ratios than in years past. The transition period — from academia to clinical practice — is critical for nurses to develop the necessary skills.

Nurse residency programs are a structured option that achieves far more than a traditional nursing orientation. These programs can help meet graduate nurses’ educational, informational, and mental needs. Let’s examine how nurse residency programs improve patient outcomes and nurse retention, which helps hospitals save money, and how nurse leaders can advocate for transition-to-practice programs.

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Why Nurses Need Transition to Practice Programs

New graduate nurses must move from a theoretical-based academic environment into clinical practice, transitioning everything they learned in the classroom and during supervised clinical experiences to independently caring for patients.

In previous years, researchers have noted that new nurses have higher medication and practice errors than experienced nurses, contributing to stress levels and significantly impacting patient safety.

New nurses care for more complex patients in an increasingly elaborate, technologically advanced healthcare setting. Roughly 25% of new graduate nurses leave their first position within the first year. This can significantly impact hospitals that spend thousands of dollars hiring and preparing new graduates for practice.

A 2022 review of the literature found that the costs related to training and orienting new nurses comprised one of the largest expenses of nursing turnover. Some studies recorded the cost ranging upward of $62,000, and the cost of replacing a nurse may be as high as $82,000 .

One study revealed that a nurse residency program improved readiness for practice and indicated those nurses may be less likely to leave the institution. They concluded that nurse residency programs helped improve nurse retention and readiness for practice while increasing job satisfaction compared to a standard orientation program.

Exploring Accredited Nurse Residency Programs

Another study by the National Council of State Boards of Nursing (NCSBN) examined how transition-to-practice programs affect nurses in hospitals, community public health, and home health settings. During Phase 1 of the study, researchers evaluated the results of a nurse residency transition to practice program in a hospital and found significantly better outcomes.

The researchers measured the new nurses’ reported competence, self-reported errors, work stress, job satisfaction, and nurse retention levels. The data showed that transition-to-practice programs with the best results were formalized programs supported by the hospital administration, 9-12 months long, and included a floor preceptor educated in the role.

Nurse residency programs with the greatest success centered on clinical reasoning, communication, patient safety, teamwork, quality improvement, informatics, and evidence-based practice. The programs gave new graduates time to absorb and apply the information in a clinical setting.

New graduates were given time to share their reflections and get feedback from their preceptors. The researchers also found transition-to-practice programs were more successful when the content was customized so new graduates learned information based on the unit where they were working.

During Phase 2, the researchers looked at the feasibility of the same types of programs in a non-hospital setting, such as home health care or a nursing home. The data was not as conclusive, and further study is planned.

Accreditation of these programs is the next step to establishing standards of practice and ensuring evidence-based plans are incorporated in the process. For example, a rapid review found multiple inconsistencies in transition-to-practice programs. These inconsistencies included preceptorships, mentoring, duration of the program, and the length of formalized study.

Inconsistencies make it impossible for researchers to determine the effectiveness of transition-to-practice programs across multiple hospitals and to generalize research findings. Using an accredited framework increases the value to the hospital and new nurses, ensuring an evidence-based framework is used to meet goals, decrease nursing turnover, and improve nursing job satisfaction and patient outcomes.

The Accreditation Commission for Education in Nursing (ACEN) offers a transition-to-practice program accreditation, which allows for program flexibility to meet the needs of the organization and the community while ensuring the nurses and hospital are following program quality standards.

ACEN processes are guided by current practice and outcomes, following data that suggests successful transition-to-practice programs improve the nursing care quality and patient safety.

What Nurse Leaders Can Do to Support Nurses’ Transition Into Practice

Strong nursing leaders are vital to ensuring the profession successfully navigates the growing technological healthcare evolution while protecting nurses. Nurse leaders do more than develop an annual budget, monitor productivity, and represent their nursing staff. They are also role models and influence the organization at all levels.

Because nursing leaders take a broad view of how daily activities impact healthcare organizations’ goals, leaders must adapt to changing environments and help motivate their staff to achieve positive patient outcomes.

One of these roles is investing the appropriate resources to help new graduate nurses transition into the nursing profession. One way that has proven effective across multiple organizational structures is by implementing a nurse residency program .

Developing an accredited nurse transition-to-practice program helps foster a healthy work environment that retains staff and improves quality nursing care. Ultimately, these measurements improve patient outcomes and reduce hospital costs.

Promoting the investment and implementation of a transition to practice nursing program is one strategy that helps to support nurses’ mental health and lower the burnout rate. Nursing leaders can help ensure a supportive workplace where nurses feel safe to share their concerns and frustrations.

The workplace environment and culture are dictated by management and leadership. Nursing leaders can also help promote programs within the institution that reduce nursing burnout and protect mental health.

Nursing leadership also plays a role in patient education to help build stronger patient outcomes. In turn, this helps support nursing staff, especially new nursing graduates, faced with learning new skills and ensuring their patients receive appropriate education that influences long-term outcomes.

Bae, S. (2022). Noneconomic and economic impacts of nurse turnover in hospitals: A systematic review . NIH

Miller, C et al. (2023). Transition Into Practice: Outcomes of a Nurse Residency Program . SLACK Journals

Suter, A et al. (2020). Nurse Residency Programs . NIH

Transition-To-Practice . (2023). ACEN

Transition to Practice Study Results . (2023). NCSBN

Weller, Newton, J et al. (2022). Transition to Practice Programs in Nursing: A Rapid Review . NIH

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APRN transition to practice

Program development tips.

Urbanowicz, Janet PhD, RN, CPHQ, NEA-BC

Janet Urbanowicz is an assistant professor at Monmouth University, Marjorie K. Unterberg School of Nursing and Health Studies, West Long Branch, N.J.

The author has disclosed no financial relationships related to this article.

Leaving the comfort zone of being an experienced RN for a new career as an inexperienced advanced practice registered nurse (APRN) is one of the greatest difficulties of the APRN transition to practice. Although this challenge is frequently discussed in the literature, progress in creating transition programs has been slow. To date, very few formal APRN residency or fellowship transition programs exist. Practicing APRNs can advocate for a formal transition program in their organizations.

Leaving the comfort zone of being an experienced RN for a new career as an inexperienced advanced practice registered nurse (APRN) is one of the greatest difficulties of the APRN transition to practice. To date, very few formal APRN residency or fellowship transition programs exist. Practicing APRNs can advocate for a formal transition program in their organizations.

Since Brown and Olshansky's seminal work in 1997, the difficulties of advanced practice registered nurse (APRN) transition to practice have been well highlighted in the literature. 1 One of the greatest challenges is the shift in experience level APRNs encounter when they leave their positions as seasoned RNs to begin practice as new APRNs. 1 Through personal communication and published literature, new APRNs resoundingly express a lack of self-confidence as they begin their new practitioner roles. Research indicates that the quality of this career adjustment can impact APRNs' development in their new roles and their decisions to remain in the profession or not. 2 A recent literature review, spanning from 2009 through 2019, yielded 155 articles related to APRN transition to practice. An additional 34 articles specifically explored transition programs. Many of these articles discuss various specific transition programs, emphasize the challenges faced by new graduate APRNs entering practice, and share research reporting the challenges of this transition.

Although this topic has been widely discussed, few articles were found that report on formal transition programs. Based on the literature findings, progress in creating formal transition programs has been slow. Despite the 2010 Institute of Medicine report recommending residency programs for nurses following the completion of an advanced practice degree program and the support of the American Association of Nurse Practitioners and other APRN organizations, little progress has been made. 2,3 To date, few formal APRN residency or fellowship transition programs exist. It is unclear why formal APRN transition opportunities are not more common; possibilities include the short-term expense or a lack of willing preceptors. Practicing APRNs must consider advocating for themselves and their new graduate peers in order to create successful transition programs in their own organizations.

Industry changes including physician shortages, expanding access to care, and value-based reimbursements mean the NP role is growing, so it is vital that new APRNs receive proper time to hone skills and gain confidence in their decision-making with oversight from an experienced colleague. 4,5 These more-efficient models of care delivery particularly rely on APRNs. A 2018 national report by NP NOW, an NP recruitment firm, predicted a shortfall of 29,400 NPs by 2025. 3 Both NP NOW and Barnes identified a web publication by Indeed.com reporting in March 2019 that 59.7% of NP jobs were on the top 15 most-difficult-to-fill positions list and that employment turnover rates for NPs are twice that of physicians. 3,6,7 The importance of APRNs' successful transitions to practice must not be undervalued or ignored. Now more than ever, APRNs need to play a role in ensuring a purposeful transition for their new graduate colleagues to independent and autonomous practice. This article will examine the current gap in APRN transition to practice education and outline steps organizations can take to create their own formal training program.

Literature review

Although new graduate nurse transition has been studied for some time, few studies have been published regarding the transition from RN to APRN. However, when they are consulted, practicing APRNs consistently admit to the difficulties of making the transition to a higher level of practice. A review of six such published studies provide evidence for the importance of transition programs.

Poronsky conducted a literature review examining the stages and processes of transitioning from an RN to family APRN role. Although her work revealed a lack of consensus on the definitions related to each stage and phase, she determined some consistency related to associated characteristics that included anxiety, role confusion, stress, insecurity, self-doubt, apprehension, emotional turmoil, and isolation. 8 These emotional characteristics impact the transition of moving into a new role and both highlight and support what new APRNs have reported.

Barnes studied the relationship between ANP role transition, prior RN experience, and formal orientation. 6 Drawing on a convenience sample of 352 NP participants at a national conference, she administered a 16-item Nurse Practitioner Role Transition Scale. The study determined mean years of prior RN experience was 13.8 years, with only 33% of participants reporting they had received some formal orientation. Through exploratory factor analysis, the author found three dimensions that explained this transition: developing comfort, building competence in the role, and understanding the role by others. Overall, her data showed that only a formal orientation was significantly associated with APRN role transition. 6 When considering the emotional characteristics identified by Poronsky, transition programs certainly involve much more than just gaining some familiarity with a new job.

Brown and colleagues developed a written questionnaire and conducted focus group discussion based on three major headings. 9 These included building a framework for a residency or the characteristics of a successful resident; resources needed or costs impacting sustainability; and program implementation or fiscal benefits of a residency program. The questionnaire was administered to attendees at a regional NP residency forum where 52 questionnaires were completed. The participants were asked to place each theme into high and low areas of impact and feasibility. The conclusions of this study highlighted five “must-haves” that included interprofessional training, a leadership/policy component, quality improvement and scholarship, diagnostic skill honing and special skill readiness, and dedicated mentorship and role development. This article expands on the work of the first two authors to include elements of a framework for transition.

Faraz conducted an extensive integrative review of 41 articles published after 1997 related to transition and the role of the NP. 7 Three major themes emerged from the literature related to the novice NP transition into primary care. These themes were categorized as “experiencing role ambiguity,” “quality of professional and interpersonal relationships,” and “facing intrinsic and extrinsic obstacles.” The findings by Faraz align and expand on the work of Brown and colleagues.

Hart and Bowen assessed new NP perceptions of their preparation for transition into practice. 10 A national sample of 698 licensed NPs who graduated between 2006 and 2011 completed an 81-item web-based survey. This survey was previously administered but was updated and pilot-tested by the authors and several graduate students from the University of Wyoming. Data in part revealed only 62.6% of respondents either agreed or strongly agreed to having adequate clinical support in their first year of practice. Only 42.2% of respondents described feeling very well or generally prepared following graduation. Most participants, 58%, expressed extreme interest in a postgraduate residency program. Of the 50% who provided written feedback, 90% expressed the need for a postgraduate formal mentor or residency. 10 This was the largest study reviewed. It was conducted post transition but captured the consensus of the importance of a postgraduate transition.

Finally, Tracy specifically looked at the role transition of certified registered nurse anesthetists (CRNAs). 11 Online recruitment and interviewing were used to explore the perceived experiences of recently graduated CRNAs making their transition into full-time practice. Five factors emerged as being perceived as facilitating the transition to practice. These include mastery of self-efficacy and confidence, expert mentoring and guidance, supportive work environment, peer support, and previous experience as a student nurse anesthetist. Here, Tracy brings forward the student experience prior to moving into a licensed APRN role. This is the only study reviewed that reveals the importance of clinical experiences as a student.

Although these studies can be considered in the development of a transition program, to date there is little to no literature related to how transition programs might be received or how a program would impact the outcomes of length of employment, job satisfaction, confidence to practice, ability to perform, or the impact a new APRN may have on patient care.

Variation in preparation for practice

According to MidlevelU, an online hub for midlevel practitioners, a comparison of education and training shows that physicians must complete 8 years of education and 3 years of residency before practicing independently. 12 In contrast, APRNs must complete 5 to 8 years of education, depending on the state in which they receive their education, and have no residency requirements. Another comparison related to clinical hours prior to graduation shows APRNs are required to complete 500 to 1,500 clinical hours while physicians are required to complete 6,000 hours. 12 This variation in preparation to practice leaves transitioning APRNs little opportunity to gain confidence and experience prior to becoming independent practitioners.

Developing successful transition programs will require information, interdisciplinary input, and thoughtful design. Turnover is expensive, and although there will be some transition cost involved because of lower preceptor and new-hire productivity, the long-term gains related to engaging, developing, and sustaining employment of a new APRN will undoubtedly outweigh any short-term expense.

Developing a program: First steps

Annual costs per APRN trainee are estimated at as much as $100,000, with two-thirds of this expense supporting the cost of the new APRN and the rest supplementing lost preceptor productivity. 2 Justifying a program based on cost will be a key factor for incumbent APRNs interested in developing a transition to practice program at their organization. This is the first step in the process. To understand a particular organization's financials, meet with a nurse recruiter to determine turnover of new first-year APRNs and the costs associated with this turnover. Other sources include the literature from regional or national employment agencies that collect data on these statistics. Tracy has estimated the cost to replace an APRN has been as high as twice that of the APRN's annual salary. 11 Additionally, employment turnover rates for NPs, as discussed by both Barnes and Hoff and colleagues, have been reported twice as high as for physicians. 2,6 According to Nursing Solutions, Inc., annual turnover levels for acute care NPs were found in one national survey to be between 8% and 11%. 13 Smaller organizations may know their turnover rates and be able to calculate the cost. Tracy states that 83% of hospitals do not report these rates or the reasons for turnover. 11 Working on a tracking process will be key to understanding the turnover rates before and after program implementation and will help determine successful metrics related to cost.

The next step is to create a structured program that adds value to the transition process and can be measured for success. Holding focus group discussions with new and experienced APRNs, nurse educators, academic faculty, APRN students, and physicians can help determine priorities. Hart and Bowen's study reported that respondents described being the least prepared for billing and coding, simple office procedures, electrocardiogram and radiology interpretation, microscopy, and mental illness management. 10 Program standardization inclusive of objectives and milestones must be established by identifying trends described by focus group members in order to address those elements.

Program goals should include, at a minimum, sustained employment beyond 1 to 3 years, individual practitioner productivity, cost related to care, and patient-related metrics such as length of stay and patient satisfaction with their care. Other goals may be driven by individual program expectations.

Time frames for a transition program are widely variable, with the Commission on Collegiate Nursing Education (CCNE) recommending 500 hours and the state of Vermont requiring 12 months or 1,600 hours. 14,15 The number of hours may initially be driven by cost or individual progressive development by the new APRN themselves, but ultimately should be determined by program outcomes. Measuring successful transition will be paramount to determining this metric.

Preceptors matter

Once the justification for the program inclusive of cost, goals, milestones, and time frames have been agreed on, practice partnership will need to be established. 16 St-Martin and colleagues showed that preceptorship experience had a strong impact on new APRN development. 5 Preceptors who were open to teaching, provided feedback, and were allowed to function independently had a positive impact learning. 5 This mentoring is best provided by willing and experienced APRN practitioners. It has been collectively agreed on that NP residency programs cannot be implemented without motivated, trained, and compensated preceptors. 17

Traditionally, physician faculty enter into contracts with medical residency programs and receive monetary compensation to provide education and oversight to medical residents. Wiltse-Nicely and Fairman state that these payments are not available for primary care nurse residencies. 18 Historically, nurse preceptors have done this for a small stipend or hourly pay increase during the time they are in the role. This has occurred primarily at the undergraduate level in acute care settings. APRN preceptors and mentors have taken on new hires for no direct compensation. However, compensation for preceptors should not be a program barrier. Finding funding can be difficult, with many existing programs remaining self-funded. However, developing a budget or working with a local foundation to secure funding may be two options for overcoming the compensation issue.

Tools for evaluating learning outcomes

Evaluating the learning progress using standard tools is crucial to demonstrating program effectiveness. 18 The nursing community still lacks specific data on the direct impact of residency programs, which creates a gap in determining program effectiveness according to Wiltse-Nicely and Fairman. 18 Specifically, the impact of transitioning APRNs on patient outcomes is yet to be published. This is open for future research and may provide additional support for these programs. Several questionnaires have been used to measure program effectiveness related to APRNs. Many reflect qualitative descriptive and phenomenographic research approaches that have been developed by the authors and researchers who have published findings. Two widely used survey tools are noted below.

Norcini describes the wide use of Miller's pyramid to evaluate progress toward clinical competence and professional identity using the dimensions of knowledge, competence (knows how), performance (shows how), and action (does) as a framework. 19,20 The hierarchical structure of this framework evaluates individual learning progress beginning with the cognitive understanding of concepts and moving to eventual application of those concepts through psychomotor skill and behaviors. This performance-based tool has been used to assess clinical competence transition for several professions, most commonly for medical students and residents in training, since it was developed in 1990. 19 No nursing use of this tool has been found in the literature.

The Nurse Practitioner Role Transition Scale (NPRTS) is another potential tool. It is a self-report survey designed to measure NPs' perceptions of the role. It has been tested for content validity and reliability. This 16-item, 5-point Likert scale survey, published in 2015 by Strange, measures self-perceptions of the role transition experience in three dimensions: developing comfort and building competence, understanding the role, and collegial support. 21

Whatever tools are used, the importance of finding ways to measure the impact of transition programs on APRN transition experiences during the first year of practice and on patient outcomes will ensure program sustainability. 21

National support of transition programs

In the last 3 years, several organizations have begun to assist in creating opportunities to develop, standardize, and accredit transition programs. These include the GraduateNursingEDU.org website repository for fellowship programs, The American Nurses Credential Center (ANCC), the CCNE, and finally, the National Nurse Practitioner Residency and Fellowship Training Consortium, which was founded in 2018. 15,22,23

The GraduateNursingEDU.org website (GNEDU) is a resource for NPs interested in learning more about fellowship programs in their area, as well as other important issues related to practice. 15 As of 2017, NP fellowship programs by state showed that 51 states reported to the GNEDU database with 32 states reporting having some residency programs, many of these being specialty focused. 15 Eighteen states have full-practice privileges in place; however, only seven of those states offer or require some postgraduate residencies. Vermont is the only reporting state with a state board of nursing requirement that mandates a formal agreement between a new APRN and a collaborating provider for no fewer than 12 months or 1,600 hours before they can be licensed and begin practicing as an APRN when they have completed fewer than 24 months and 2,400 hours of active APRN practice in a specialty and population focus. 15

The ANCC published the Practice Transition Accreditation Program (PTAP) guidelines in 2016. 22 This program has developed criteria and guidelines for organizations to develop residency or fellowship programs. According to the ANCC website, there are 381 sites to date that have one or more programs accredited by the ANCC. 22 However, the vast majority of these are for new graduate nurses transitioning into practice. Although PTAP does not prescribe, it does define expected domain criteria to be met as described by the applicant organization. This accreditation must be renewed every 3 years.

The CCNE is one of the most recognized and most influential nursing education accrediting agencies in the US. In January 2019, it posted a press release stating the formation of a Nurse Practitioner Residency/Fellowship Standards Committee. This committee has been charged with creating accreditation standards that can guide academic nursing residency programs nationwide. Currently, the CCNE requires 500 hours of clinical training prior to graduating with an advanced practice degree. 14

The National Nurse Practitioner Residency and Fellowship Training Consortium, located in Washington, D.C., is another organization that provides accreditation opportunities. 23 This national private nonprofit 501(c)(3) charitable organization was created to advance the model and rigor of postgraduate NP training programs, both residency and fellowship, through accreditation. The Consortium accredits nurse practitioner postgraduate (residency or fellowship) training programs in the US that are based in a variety of settings such as Federally Qualified Health Centers Veterans Affairs, academic practices, or large health systems.

Because APRNs are expected to be leading members of healthcare teams, formal training is essential to the transition process. 20 Clinical readiness, leadership skills, communication, and professional identity are key components to the development of new APRNs. Creating a well-designed transition program that offers a structured path to independent practice will undoubtedly have an overall positive impact on the bottom line, productivity, and patient outcomes. Understanding current internal data, reviewing resources provided by organizations that are developing standards for these programs, and connecting with colleagues from around the country are all great assets available toward developing a successful program.

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APRN; confidence; fellowship; residency; skill acquisition; transition to practice; turnover

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Transition to Practice Report

This report is a companion to the Transition Evidence Grid. The report synthesizes all the evidence on transitioning new nurses to practice. It illustrates the importance of formal transition programs in protecting the public, and it provides the data that support the components of the Transition Regulatory Model. This report was adopted by the May, 2008 NCSBN Board of Directors.

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Development of the novice nurse practitioner role transition scale: An exploratory factor analysis

Hilary barnes.

1 School of Nursing, University of Delaware, Newark, Delaware,

Asefeh Faraz Covelli

2 School of Nursing, The George Washington University, Washington, District of Columbia,

Jonathan D. Rubright

3 National Board of Medical Examiners, Philadelphia, Pennsylvania

Background:

Novice nurse practitioner role transition (NNPRT) can be described as stressful and turbulent, leading to decreased job satisfaction and increased intent to leave. No published instrument exists to measure NNPRT. Thus, researchers, educators, and administrators are limited in their ability to measure the concept and therefore understand the factors that lead to a successful, or unsuccessful, role transition experience. An instrument with evidence of validity and reliability is needed to conduct large-scale and systematic examinations of NNPRT.

The purpose of this study was to develop and examine the initial factor structure of a novel instrument that measures NNPRT.

Initial item development was guided by concept analysis, literature review, and qualitative data. Face and content validity were established from expert review. Using pilot data from 89 novice nurse practitioners (NPs), an exploratory factor analysis (EFA) was conducted to examine the instrument's internal factor structure.

The NNPRT Scale includes 40 items that measure an individual's perception of their role transition experience. The EFA revealed a five-factor structure: organizational alignment, mentorship, sense of purpose, perceived competence and self-confidence, and compensation.

Implications for practice:

In an evolving health care system, provider well-being is at the center of workforce, educational, and organizational conversations. Understanding how to optimize the workforce and prepare NPs for health care delivery is increasingly important. The NNPRT Scale will allow for large-scale examinations of the factors that influence NP role transition, as well as assess interventions to prepare and support novice NPs' transitions.

Introduction

Rapidly evolving care delivery, including increased provider workloads, greater complexity of patient care needs, and global pandemics place health care providers at risk for decreased well-being and poor workforce outcomes. In particular, poor nursing well-being is problematic because it is linked to decreased patient satisfaction and poor quality of care ( McHugh et al., 2011 ), prompting the need to focus on supporting workforce well-being as an intervention to enhance care delivery and productivity ( Klein et al., 2019 ; Sikka et al., 2015 ). It is important that providers are particularly vulnerable to poor well-being during transition to a new professional role, which can be taxing for novice clinicians ( Moran & Nairn, 2018 ).

More specifically, nurse practitioners (NPs) are at risk for poor transition experiences when starting their first NP position ( Barnes, 2015 ; Brown & Olshansky, 1997 ; Cusson & Strange, 2008 ; Faraz, 2019 ; Kelly & Mathews, 2001 ). Novice NP role transition (NNPRT) has been described as both stressful and turbulent, and two decades of research has found this time is rarely easy and often marked by the shift from an experienced, expert status in the registered nurse (RN) role to an inexperienced novice in the NP role. This change in professional identity often leads to decreased confidence and job satisfaction, which can impair role development ( Barnes, 2015 ; Brown & Olshansky, 1997 ; Kelly & Mathews, 2001 ) and lead to an increased intent to leave one's current position ( De Milt et al., 2011 ; Faraz, 2017 ; Sargent & Olmedo, 2013 ). These negative workforce outcomes not only affect employment continuity but also the decision to remain in the profession ( Cusson & Strange, 2008 ), affecting cost to employers, patient care continuity, and placing patients at risk for poor clinical outcomes ( Chanfreau-Coffinier et al., 2019 ; Katz et al., 2015 ; Lam et al., 2020 ).

With these known costs to patients specifically and to the health care system generally, NNPRT is an important phenomenon to study. This is especially urgent because the NP workforce is growing, with approximately 28,000 NPs yearly entering a workforce ( Salsberg, 2018 ) that delivers safe, high-quality, and cost-efficient patient care in the United States ( Buerhaus, 2018 ; Swan et al., 2015 ). Supporting novice NPs is critical to improving the patient experience and the effectiveness and efficiency of care ( Perlo et al., 2017 ; Sikka et al., 2015 ). Changes in how novice NPs are supported, whether in the form of organizational or educational interventions, are needed. To understand and empirically evaluate such interventions, a means to measure this concept is needed.

No published instrument currently exists to measure NNPRT. An instrument with evidence of validity and reliability is needed to conduct large-scale and systematic examinations of NNPRT and, subsequently, its association with NP workforce and patient outcomes. To bridge this literature gap, the authors developed a novel instrument that measures NNPRT, pilot tested it in a sample of novice NPs, and examined the internal factor structure ( McCoach et al., 2013 ). In this article, we describe the development of the NNPRT Scale and the results of the exploratory factor analysis (EFA).

Conceptual framework

The authors developed a conceptual framework to guide development of the NNPRT Scale. A concept analysis of NP role transition identified the personal and environmental factors that promote, or inhibit, a successful NP role transition experience ( Barnes, 2015 ). More recently, Faraz (2016 , 2017 ) expanded the concept, from the results of a literature review and qualitative study, to include contemporary workforce needs ( Perlo et al., 2017 ; Sikka et al., 2015 ). This collective body of work revealed three domains driving NNPRT: 1) educational preparedness ; 2) role acquisition with subdomains role ambiguity, self-confidence, perceived competence, and mentorship; and 3) job satisfaction with subdomains professional autonomy, quality of professional and interpersonal relationships, time to complete work, job benefits, sense of meaning, and work–life balance. This conceptual framework guided initial item generation of the NNPRT Scale (Figure ​ (Figure1 1 ).

Novice NP role transition conceptual framework that guided item development. NP = nurse practitioner.

Initial item and scale development

Instrument development was conducted in several sequential stages. Following item generation, face and content validity were assessed via expert review and feedback from a sample of recent NP graduates. Items were refined based on this feedback. Subsequently, pilot data were collected from a new sample of novice NPs working in their first NP position to support initial psychometric testing. These steps are outlined in more detail below. Institutional Review Board approval for this study was obtained before data collection.

Item generation

The process of instrument development begins with the generation of a sufficient number of items to assess content validity ( McCoach et al., 2013 ). Guided by the NNPRT conceptual framework (Figure ​ (Figure1), 1 ), the authors developed a pool of 77 items across the three domains, and six additional items were adopted with permission from an earlier NP role transition instrument that has not been published in the peer-reviewed literature (Dr. Regina Cusson, personal communication, November 26, 2018; Strange, 2015 ). The initial NNPRT Scale included 83 items: five under educational preparedness , 30 under role acquisition , and 48 under job satisfaction .

The varying proportion of items across the three domains was supported by evidence of the relative importance of each domain to NNPRT. For example, receiving a graduate-level education is described as an antecedent of NNPRT; that is, all initial NP education occurs before working as an NP ( Barnes, 2015 ). Within the context of the actual role transition experience (i.e., after the NP starts the first position), educational background is described as a lack of feeling prepared for practice ( Faraz, 2016 , 2017 ). Item development under educational preparedness focused on this theoretical definition (i.e., NPs' feelings of being prepared for entry-level practice). Comparatively, evidence supports that the other two domains, role acquisition and job satisfaction , and the 10 subdomains are more influential to NNPRT because they are present during the actual experience of NNPRT ( Faraz, 2019 ; Kelly & Mathews, 2001 ; Sargent & Olmedo, 2013 ; Zapatka et al., 2014 ). Therefore, item development was weighted to reflect the relative importance of these two domains to the overall concept.

Finally, we chose a 6-point Likert response scale (1 = very strongly disagree to 6 = very strongly agree ). Using more response points, compared with Likert scales with five or fewer responses, can improve the sensitivity of the scale. Scales with 6 points can provide consistent responses across participants ( McCoach et al., 2013 ).

Face and content validity

Face and content validity of the NNPRT Scale items were established via feedback from a panel of experts on NP role transition and a sample of recent NP graduates.

Expert review

We solicited feedback on the NNPRT Scale items from a panel of four NP role transition experts. Individuals were selected based on their reputations as experts and their scholarship on NP role transition, education, and training. Experts were asked to rate the relevance of each item to the concept of NNPRT using a 4-point Likert scale (1 = not relevant to 4 = highly relevant ). Experts had the option to provide comments or suggest revisions for each item. Data were collected Spring 2019 via an online Qualtrics survey.

For each item, we calculated the content validity index ([CVI]; McCoach et al., 2013 ) by summing the number of experts that rated the item 3 ( quite relevant ) or 4 ( highly relevant ) and dividing by the number of experts ( N = 4). The higher the CVI, the greater the agreement across experts of the item's relevancy to the concept; thus, a CVI equal to 1 indicates complete agreement among experts. Forty-seven items had CVIs equal to 1; all but one item was kept. The omitted item (“I wish I had stayed in the RN role”) was removed based on reviewers' comments questioning the ability of participants without RN experience to respond to the item. Twenty-seven items had CVIs of 0.75, which is lower than the recommended 0.80 for retaining items ( McCoach et al., 2013 ); however, given that our group consisted of four experts, agreement among three would calculate to a maximum CVI of 0.75. Thus, we evaluated each of these items individually considering the experts' comments, the item's similarity with higher scoring items, and the research team's knowledge of the concept. Based on this analysis, 11 items were removed and retained items were reworded as necessary. Of the seven items that had a CVI of 0.5, we omitted three and retained and revised four items based on reviewers' comments and alignment with the concept. The two items with a CVI of 0.25 were omitted. Based on experts' comments and each item's CVI, we omitted a total of 17 items from the original pool of 83 items.

NP graduate review

The refined set of 66 items was administered to a convenience sample of seven recent NP graduates from the first two authors' institutions. Participants were asked to provide feedback on the items and rate each item's importance to NNPRT. All respondents received a $10 gift card for participating. Feedback was collected in the Summer of 2019 via a REDCap survey. Based on comments provided about the importance of items to NNPRT, we omitted an additional nine items. By eliciting feedback from experts and recent NP graduates, we established face and content validity of the NNPRT Scale and retained 57 items for the next stage of instrument development.

Initial psychometric testing of the novice nurse practitioner role transition scale

Sample and data collection.

We used a cross-sectional, nonexperimental survey design to collect data from a convenient sample of novice NPs. Data collection occurred online via a secured, confidential Qualtrics survey over a 3-month period at the end of 2019 and early 2020. Study participants were recruited through the American Association of Nurse Practitioners (AANP) “Career Starter Membership,” which is designed for new NPs within the first year of their career ( AANP, 2020 ). Three email blasts describing the study and containing a link to the survey were delivered by the AANP to a random sample of 2,000 “Career Starter” members. A $10 gift card was offered to participants in the initial email blast and the gift card amount was increased to $25 in follow-up emails to increase the response rate. We also recruited novice NPs through snowballing efforts using our professional and academic networks.

On clicking the survey link, participants were directed to a survey landing page describing the study, their rights as a study participant, and ensuring confidentiality of responses. Participants were required to check a box indicating their decision to participate in the study (“I consent, begin the study”) or not (“I do not consent, I do not wish to participate”). When an individual agreed to participate, they were directed to the next page to determine eligibility. The inclusion criteria to participate in the study were: 1) working as a NP; 2) working in the first NP position; 3) working in the first NP position for less than 12 months; and 4) 18 years or older. Participants needed to meet all eligibility requirements to proceed to the survey. If an individual agreed to participate and met the eligibility criteria, the NNPRT Scale was presented, followed by a demographic survey. The survey took approximately 15–20 min to complete. All participants who completed the survey were offered the opportunity to receive a gift card for their time by providing their name and email address on a second secured survey that was kept separate from their study responses. No participant information was shared between the NNPRT survey and the incentive request.

Novice nurse practitioner role transition scale

The NNPRT Scale measured an individual's perception of their NP role transition experience. Higher total scores indicated a more positive role transition experience, and lower scores indicated a less positive role transition experience. The total score is calculated by summing all items for each respondent and dividing by the number of items. The range of possible total scores is 1–6.

Demographic survey

Demographic information included personal characteristics (e.g., age, gender, race, income), professional characteristics (e.g., initial NP education and licensing, national NP certification, years of prior RN experience), and current employment characteristics (e.g., practice setting and specialty, receiving a formal orientation, and hours worked).

Data analysis

Analyses were conducted using STATA-15.1/SE. Data were cleaned and seven items were reversed coded. We removed participants who did not meet inclusion criteria or had incomplete NNRPT Scale data. We retained responses with complete NNPRT Scale data regardless of the completeness of the demographic survey responses. We examined response patterns for any aberrant response behaviors, such as response set bias (e.g., “very strongly agreeing” with all items regardless of the item's content) ( Polit & Beck, 2017 ). If response bias was a concern, the participant was removed. The final sample included 89 novice NPs. Sample characteristics were calculated using frequencies, percentages, ranges, mean values, and standard deviations.

Item analysis and reliability

Item analysis included calculating descriptive statistics (e.g., histograms, mean, median, SD, range) for each item and the total NNPRT Scale score. An initial total score was calculated using 57 items. Using a correlation matrix, correlations between each item and the total score were evaluated ( McCoach et al., 2013 ). Items that were correlated with each other at 0.85 or greater were identified as high correlations may indicate redundancy among the items. In the event of two highly correlated items, we reviewed the item stems and decided which of the pair to retain and which to omit ( McCoach et al., 2013 ). To assess the instrument's internal reliability, we calculated Cronbach alpha for the total score along with a leave-one-out analysis to identify whether the reliability coefficient improved with the removal of any single item ( Cronbach, 1951 ).

Exploratory factor analysis

Exploratory factor analysis is an important and necessary stage in instrument development to explore the underlying factor structure and identify the smallest number of factors that explain how items correlate with each other ( McCoach et al., 2013 ). Although a conceptual framework guided item generation, an EFA does not impose an a priori theoretical structure on the items and allows the unknown factor structure to emerge from the data ( Browne, 2001 ; McCoach et al., 2013 ). Given our small sample size, we used a principle axis factor analysis because it can handle potentially nonnormal data and has a greater ability to recover weak factors ( Briggs & MacCallum, 2003 ; Cudeck, 2000 ). Additionally, to assess sampling adequacy, we ran a Kaiser–Meyer–Olkin (KMO) test; a KMO value greater than 0.60 suggests data are adequate for conducting an EFA ( Kline, 1994 ).

To determine the appropriate number of factors to extract from the data, we used five approaches: Kaiser's (1960) criteria, scree plot ( Cattell, 1966 ), parallel analysis ( Horn, 1965 ), Velicer's (1976) minimum average parcels (MAP), and interpretability ( Fabrigar et al., 1999 ; Gorsuch, 1983 ). Using Kaiser's (1960) criteria, we identified factors with eigenvalues greater than 1.0. However, this approach often overestimates the number of factors ( McCoach et al., 2013 ); thus, we employed the additional approaches listed above. The scree plot involved plotting the eigenvalues from our observed data on a curve, and the point at which the curve stops decreasing and flattens suggests the number of factors to retain ( Cattell, 1966 ; McCoach et al., 2013 ). We then ran a parallel analysis, which calculates eigenvalues from simulated data ( Horn, 1965 ; McCoach et al., 2013 ). We ran the parallel analysis using 1,000 random data sets and then overlaid the results onto a single plot with the scree plot. Factors with eigenvalues in the observed data that are larger than the simulated data suggest “true” factors ( McCoach et al., 2013 ). We also calculated the MAP, which is the average squared partial correlation between items and identifies the smallest value associated with the fewest number of factors ( McCoach et al., 2013 ; Velicer, 1976 ). The final step, interpretability, included coupling the collective results from these approaches with our knowledge and understanding of the theoretical expectations of NNPRT to decide on the final number of factors to extract in our EFA ( Fabrigar et al., 1999 ; Gorsuch, 1983 ).

Using the extracted factor structure, we estimated an oblique rotation (promax) that allowed the extracted factors to correlate ( McCoach et al., 2013 ). The rotated factor matrix was examined and items with pattern coefficients of 0.40 or greater were identified as contributing to a factor and retained. Items were removed if the pattern coefficient was less than 0.40 on all factors or if the item cross-loaded on two or more items with values of 0.32 or greater, and anytime an item was removed from the instrument, we reran each step of the EFA ( Cabrera-Nguyen, 2010 ).

Sample characteristics

Participant demographics for the final sample ( N = 89) are shown in Table ​ Table1. 1 . The sample was 93.2% female, 69.3% White, and was on average 38 years old (range: 25–57 years). The majority of participants (88.8%) held a national NP certification in primary care. A Master's degree was the highest reported degree for initial NP education (83.2%). Almost half of participants (47.2%) completed their didactic NP coursework (not clinical) primarily online, with 36.0% completing a program that delivered didactic content via a combination of online and face-to-face delivery methods. Among participants who reported prior RN experience (97.8%), 87.2% reported working as a RN for more than 5 years. Eight percent of participants reported participating in a NP residency or fellowship program; however, almost two thirds of those who did not, received a formal orientation in their first position (62.2%). There are currently no national data sources with characteristics of novice NPs. However, characteristics of the novice NPs in our sample were similar to samples recruited for two recent studies on the novice NP workforce ( Faraz, 2019 ; Faraz & Salsberg, 2019 ).

Note: N = 89 unless otherwise noted. Selected response categories provided. Percentages may not equal 100 due to rounding. CHC = community health clinic; FQHC = federally qualified health center; NP = nurse practitioner; RN = registered nurse.

Preliminary item analysis and reliability

From the correlation matrix (57 items), we identified four item pairs with correlations greater than 0.85. After reviewing the item stems, we removed three items from the NNPRT Scale leaving 54 items. The reliability (Cronbach alpha) of the 54-item NNPRT Scale was 0.96. Total reliability did not improve with the removal of any item. Individual item analysis and correlation matrix results are available on request from the authors.

Using the set of 54 items, an EFA was performed to examine the internal factor structure of the NNPRT Scale. The KMO test was 0.80, which suggested the data adequate for conducting an EFA ( Kline, 1994 ). Kaiser's criteria (eigenvalues >1) revealed 11 factors. The scree plot, parallel analysis, and MAP suggested extracting five factors. Based on the results of these factor extraction approaches, we decided to extract five factors, which agreed with our knowledge of the conceptual underpinnings of NNPRT. Using the five-factor structure, we ran the oblique rotation (promax) and removed items based on the factor loading criteria discussed above. We iterated this process four times until no items were identified for removal. In total, we removed 14 items leaving 40 items across five factors.

The reliability of the final 40-item NNPRT Scale was 0.96. The KMO test increased to 0.85, again supporting adequate data with the smaller set of items. Kaiser's criterion suggested seven factors. The scree plot and parallel analysis again identified five factors (Figure ​ (Figure2), 2 ), and the MAP also suggested a five-factor structure. The final set of items, pattern coefficients, and factors can be seen in Table ​ Table2. 2 . Correlations between the five factors ranged from 0.18 to 0.65, suggesting the rotation technique was appropriate ( McCoach et al., 2013 ).

Novice NP role transition scale EFA scree plot and parallel analysis. EFA = exploratory factor analysis; NP = nurse practitioner.

Factor structure of the NNPRT scale

Note: Exploratory factor analysis rotated pattern matrix; NP = nurse practitioner.

The final NNPRT scale

On average, the novice NPs in our sample reported moderate role transition experiences; the mean 40-item NNPRT Scale total score was 4.45 (SD: 0.64; range: 2.38–5.60). The five factors extracted from the data included (Figure ​ (Figure3): 3 ): 1) organizational alignment (14 items); 2) mentorship (four items); 3) sense of purpose (12 items); 4) perceived competence and self-confidence (eight items); and 5) compensation (four items). Of the five factors that emerged from the data, two of the factors measure intrinsic concepts (sense of purpose; perceived competence and self-confidence) and three measure extrinsic concepts (organizational alignment, mentorship, and compensation).

Factor structure of the NNPRT Scale. NNPRT = novice nurse practitioner role transition.

Organizational alignment

Factor 1 measures the fit of the NP with their employment setting. Many of the items included in this factor measure organizational structures, such as professional autonomy, quality of relationships, feeling respected by others, and those structures that contribute to work–life balance. One item (“I belong in my practice setting”) was originally developed under the domain role acquisition (Figure ​ (Figure1). 1 ). However, the item loaded with other items focused on the organization in which the NP works, suggesting that the factor is not just about job satisfaction, but more about how well the NP feels welcome and integrated into the organization.

Factor 2 measures the availability and perceived quality of mentorship in the first NP position. Mentorship is a critical aspect and is cited as a facilitator of NNPRT ( Faraz, 2019 ; Sargent & Olmedo, 2013 ; Zapatka et al., 2014 ). It has been theorized that mentorship of novice NPs may lead to increased self-efficacy, improved job satisfaction, and retention ( Barnes, 2015 ; Harrington, 2011 ; Hill & Sawatzky, 2011 ). Mentorship has been described as an environmental factor or form of extrinsic support ( Barnes, 2015 ); however, the emergence of mentorship as a factor separate from measures of the NP's organizational fit demonstrates its importance to the larger concept of NNPRT. It may also reflect that mentorship does not need to come from the organization, and NPs may find mentorship outside of their practice settings.

Sense of purpose

Factor 3 measures the NP's internal feelings about caring for patients and reflected engagement within the NP role ( Barnes, 2015 ). This concept was originally included as a subdomain under job satisfaction (referred to in Figure ​ Figure1 1 as sense of meaning ) as a concept related to the NP position. Having a sense of purpose and finding meaning in their work by helping patients and making a difference in their communities has been cited by novice NPs as positive factors ( De Milt et al., 2011 ; Faraz, 2019 ; Kelly & Mathews, 2001 ).

Perceived competence and self-confidence

Similar to factor 3, factor 4 measures intrinsic concepts related to NNPRT. Factor 4 measures the NP's feelings surrounding their ability to meet the demands of the position and the needs of their patients, as well as feelings that they are performing well in their job. This is a well-established concept, beginning with the seminal “From Limbo to Legitimacy” framework ( Brown & Olshansky, 1997 ) and confirmed by other researchers ( Kelly & Mathews, 2001 ; Faraz, 2016 , 2017 ).

Compensation

The final factor 5 measures the NP's satisfaction with their financial compensation. Low wages and a lack of benefits compared with colleagues and prior RN compensation have been cited as negative factors for novice NPs ( Faraz, 2019 ). It is important to distinguish that NPs have reported dissatisfaction with a lack of parity in compensation as compared with their peers for similar work and are more interested in fair rather than high salaries ( Faraz, 2019 ).

We developed the NNRPT Scale to measure the concept of novice NP role transition. The NNPRT conceptual framework, informed by our combined programs of research, guided initial item development. Face and content validity were established from panels of NP role transition experts and recent NP graduates. Using data from a pilot sample of novice NPs ( N = 89), we conducted initial psychometric testing to obtain evidence of reliability and examine the internal factor structure of the instrument. The results of the pilot EFA revealed five factors: 1) organizational alignment; 2) mentorship; 3) sense of purpose; 4) perceived competence and self-confidence; and 5) compensation (Figure ​ (Figure2). 2 ). The final NNPRT Scale includes 40 items that measure an individual's perception of the role transition experience.

The United States health care system is challenged with ensuring the delivery of safe, effective, and efficient patient care. Over the next 10 years, empirical evidence will be required by administrators, clinicians, and researchers to optimize preparedness and performance of the NP workforce to improve access to care, patient outcomes, and costs ( Buerhaus et al., 2019 ). Optimizing care delivery and efficiency, however, can only be achieved if provider well-being is also addressed ( Perlo et al., 2017 ; Sikka et al., 2015 ). Additionally, the forthcoming Future of Nursing 2020–2030 committee identifies nurses' well-being as important to the delivery of high-quality patient care ( National Academy of Medicine, 2020 ). Thus, there is a critical need to understand novice NP transition to practice. Without an instrument with evidence of validity and reliability, conducting large-scale examinations of NNPRT to identify interventions or approaches that can support successful development of novice NPs is limited.

Future research includes collecting data with a different sample of novice NPs for further psychometric testing. The current five-factor structure will provide the theoretical structure for additional testing and an a priori hypothesis of the factor structure for use in a confirmatory factor analysis ( Cabrera-Nguyen, 2010 ; McCoach et al., 2013 ). Additionally, we encourage the use of the NNPRT Scale in future studies and practice change projects aimed at increasing our collective understanding of NNPRT, as well as developing and testing interventions that will support NPs' entry into the workforce.

Limitations

The study is not without limitations. As with any self-report survey, there is the potential for sampling error or bias ( Polit & Beck, 2017 ). For the pilot study, we did not achieve the recommended minimum sample size of 5–10 participants per item ( Cabrera-Nguyen, 2010 ; McCoach et al., 2013 ). However, our data were considered adequate for an EFA via the KMO test. Collecting data from novice NPs is challenging and researchers have used indirect methods (i.e., snowballing) to augment participant recruitment ( Faraz, 2017 ; Faraz & Salsberg, 2019 ). Our data collection relied on both direct recruitment (i.e., emails to AANP members) and snowballing methods. Additionally, we were unable to target the AANP email blasts to NPs who met our inclusion criteria. Thus, we were unable to calculate a response rate because we cannot confirm how many NPs meeting the inclusion criteria received a link to the study.

Conclusions

Studying NNPRT in today's health care environment is critical as the number of NP graduates has increased by over 200% since 2008 ( Salsberg, 2018 ), and NP employment across settings is growing ( Barnes et al., 2018 ; Martsolf et al., 2018 ). Additionally, the current global COVID-19 pandemic, coupled with an already increasingly complex health care system, is underscoring the importance of rapid and successful transition during this critical time in NPs' professional role development ( Wolfe, 2020 ). We anticipate the NNPRT Scale will be useful to organizations, employers, and educators needing evidence to guide development of interventions to support novice NPs. Ensuring that researchers, educators, and administrators have an instrument with strong psychometric properties to measure NNPRT will improve examination of the concept across practice settings, educational experiences, and regulatory environments.

Acknowledgments

Acknowledgements: The authors would like to thank Drs. Regina Cusson, Margaret Flinter, Ann Marie Hart, and Rachael Crowe for their expert feedback during the early stages of item development. The authors would also like to specifically thank Dr. Regina Cusson for permission to adopt selected items for the NNPRT Scale. The authors also thank the American Association of Nurse Practitioners (AANP) and the AANP Research Committee for their assistance with data collection. This study was funded by pilot grants from Sigma Phi Epsilon Chapter and The George Washington University School of Nursing.

Competing interests: The authors report no conflicts of interest.

Authors' contributions: H. Barnes and A. Faraz Covelli conceptualized the study, generated scale items, collected the data, and interpreted the results. H. Barnes performed the data analyses and was primarily responsible for writing the manuscript. A. Faraz Covelli contributed substantially to the intellectual content of early drafts of the manuscript. J. D. Rubright guided the processes of instrument development, data analysis, and results interpretation. All authors read and revised the manuscript.

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Glimpses into the transition world: New graduate nurses' written reflections

Affiliations.

• 1 Graduate School of Nursing, Midwifery and Health, Victoria University of Wellington, New Zealand. Electronic address: [email protected].
• 2 Graduate School of Nursing, Midwifery and Health, Victoria University of Wellington, New Zealand.
• 3 Graduate School of Nursing, Midwifery and Health, Victoria University of Wellington, New Zealand; Royal Liverpool and Broadgreen University Hospital Trust, United Kingdom.
• PMID: 29032292
• DOI: 10.1016/j.nedt.2017.09.022

Background: This study was born out of our reflections as educators responsible for helping new graduate nurses transition into their first year of professional practice through a formal education programme. Finding ourselves wondering about many of the questions the students raised with us, we set about looking more closely at what could be gleaned from the students' experience, captured in their written work over the course of a year.

Objectives: To identify the challenges and learning experiences revealed in reflective assignments written by new graduate nurses undertaking a postgraduate course as part of their transition to registered nurse practice.

Study design, setting and participants: Data consisted of the written work of two cohorts of students who had completed a postgraduate university course as part of their transition to new graduate practice in New Zealand. Fifty four reflective essays completed by twenty seven participating students were collected and their contents analysed thematically.

Results: Five key themes were identified. The students' reflections noted individual attributes - personal and professional strengths and weaknesses; professional behaviour - actions such as engaging help and support, advocating for patients' needs and safety and putting their own feelings aside; situational challenges such as communication difficulties, both systemic and interpersonal, and the pressure of competing demands. Students also identified rewards - results they experienced such as achieving the nursing outcomes they desired, and commented on reflection as a useful tool.

Conclusions: The findings shed light on the experiences of new graduates, and how they fare through this critical phase of career development. Challenges relating to the emotional labour of nursing work are particularly evident. In addition the reflective essay is shown to be a powerful tool for assisting both new graduate nurses and their lecturers to reflect on the learning opportunities inherent in current clinical practice environments.

Keywords: Emotional labour; New graduate nurse; Nursing education; Reflection; Transition to practice.

Copyright © 2017 Elsevier Ltd. All rights reserved.

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Transition to Nursing Practice

Introduction.

This second assessment is an action plan for the three identified learning needs from the first assessment. The reflective self-assessment (assessment one) allowed me to identify three learning needs derailing my professional development objective. Three identified learning needs from the first assessment were minimal knowledge about The Nursing and Midwifery Board of Australia’s (NMBA) approved practice areas, going above and beyond for my patients and fellow work colleagues, and being too self-critical (Nursing and Midwifery Board of Australia, 2016). This second assessment examines how these learning needs will be met to improve my career growth and get me registered by NMBA. Specifically, the action plan integrates the quality improvement activities, timelines, resources, situational awareness, and risk management for each learning need, as discussed below.

Learning need 1

In my daily evidence-based nursing practices, going above and beyond for my patients and fellow work colleagues for my patients and fellow work colleagues is my other learning need. I often work beyond the working hours out of my desire and willingness to support the nursing care delivery processes. I have established loyalty with patients in these efforts because they believe I tirelessly care for their well-being and health. In addition, my colleagues have also benefited from my tireless devotion by sometimes working overtime, which sometimes eases their work burden and improves our relationships (Rush et al., 2019). Although these positive outcomes have been realized, my weakness is working beyond the stipulated time, even when the supervisors render no request or remuneration. To address this weakness, I will utilize work management seminars and workshops to avoid transcending my team members and patients. These events are often organized at the organizational level to empower the nurses and other professionals with soft skills such as controlling, leading, organizing, and planning to avoid time mismanagement and conflicts among team members. Once I learn and implement these skills in my daily nursing practices, I will likely work within the defined time limits without exceeding others (Kaihlanen et al., 2018).

Nevertheless, failure to address this learning need may give rise to conflicts with my workmates. Sudden and unrealistic expectations may emerge from workmates who may negatively perceive my transcending as a way of making the management look at them as average workers. Such expectations may make some of my colleagues jealous and think I am exposing their weaknesses to the top management. In due course, my interpersonal and interprofessional collaborations may significantly decline as people perceive me as too ambitious (Lindfors, Flinkman & Kaunonen, 2022). I will address this risk by communicating to my colleagues that I love transcending while executing my daily nursing practices. I often emphasized during staff meetings that transcending gives me the confidence to know that I am causing a positive impact on patients’ lives and easing the workload for my workmates. In addition, I am aware that nursing practices require tireless devotion by registered nurses to improve patients’ health and well-being. Focus is placed on patients’ healthcare needs rather than personal interests to demonstrate professionalism for registered nurses. Similarly, transcending for workmates helps to ensure that nursing practice gaps due to late coming are mitigated healthcare delivery proceeds even in the partial absence of nurses on duty. These efforts ensure that patients’ urgent and non-urgent health conditions are addressed to avoid potential mortalities (Rush et al., 2019).

Additionally, I will use the internet to conduct personal readings about how to avoid transcending for workmates and clients. Such a resource will allow me to access many articles to give me insights about benefits, demerits, and possible solutions to avoid transcending. I expect to start reading about transcending from May 1, 2023, to May 31, 2023. Also, I will attend quarterly work management workshops and seminars to improve this learning need (Lindfors, Flinkman & Kaunonen, 2022).

Learning need 2

Being too self-critical is my other weakness as a registered nurse. As part of my situation awareness, I have often demonstrated self-critical when reflecting on my daily evidence-based practices like diagnoses, treatments, and feedback collection. This practice has made me mostly acknowledge my flaws and avoid repeating them in future practices. For instance, I often made inaccurate documentation when handling patients’ healthcare needs during staff shortages. I would try to multitask, but in the end, I would recognize flaws in my documentation (Lindfors et al., 2022). After a self-critical evaluation, I would acknowledge that busy schedules and fatigue were responsible for my flaws. Through self-criticism, I have been able to prioritize my task schedule, exercise, and adopt a healthy lifestyle to mitigate these adverse nursing scenarios. Despite these positive outcomes, self-critical is a weakness in my work because it makes me overthink when handling my life experiences. I believe being too self-critical and overthinking situations affects my work because it makes me spend much time brainstorming on potential solutions to challenging nursing experiences (Kenny et al., 2021). For example, there have been incidences where some of my patients have taken longer than expected to recover despite my tireless devotion to delivering nursing care. This has been due to minimal clinical abilities in delivering critical care. Because of self-critical, I have sometimes felt low self-motivation, low self-esteem, and social anxiety. However, I wish to seek assistance from a behavioral therapist to improve my mental strength. I will likely have mitigated negative thoughts and habits through the behavioral therapist’s efforts. My mindset will likely be set on my strengths and successes while knowing I have room to improve my experience, skills, and knowledge in dealing with negative emotions (Lindfors, Flinkman & Kaunonen, 2022).

If I do not manage the adverse effects of being too self-critical, my self-esteem, self-confidence, and self-motivation may significantly decline, resulting in poor work performance. Negative thoughts may surpass my positive thought as the focus would be placed on failures instead of achieved success and strengths (Lindfors et al., 2022). To manage this potential risk, I will attend leadership seminars organized by employers to improve my critical thinking, decision-making, and problem-solving skills. I will likely use organizational resources such as computers and internet connections to attend the seminars. Alternatively, experts invited to the seminars will be another resource for me to utilize and express my concerns about self-criticism. I plan to utilize leadership seminars starting May 31, 2023, and July 31, 2023. In this same timeline, I will seek services from a behavioral therapist to improve my emotional intelligence so that self-criticism can be used to enhance my nursing practices (Butler, 2023).

Learning need 3

Minimal knowledge about the Nursing and Midwifery Board of Australia’s approved practice areas is one of my learning needs. As a registered nurse, I must meet the specialty and general registration requirements since I am still a student nurse. To meet these requirements, I will seek additional theoretical knowledge and extra clinical abilities in other areas of nursing. Theoretical knowledge will be acquired from personal reading and research about nursing practice areas. I will broaden my theoretical knowledge by reading journal articles and books about NMBA-approved practice areas (Nursing and Midwifery Board of Australia, 2016). In addition, I will also pursue further studies in extra clinical abilities in nursing areas such as critical care and geriatric nursing to improve my leadership competencies in providing quality nursing care (Kenny et al., 2021). Based on my vast experience in peri-operative nursing will lay a strong foundation for demonstrating effective communication, problem-solving, decision-making, and critical thinking competencies in my endeavors. This factor will empower me to apply emotional intelligence and prioritize integrity and mutual respect in my endeavors. These competencies will likely improve as I pursue further education when I pass all the assessments that test my ability to fulfill specialty and general registration requirements (Butler, 2023).

If I do not improve my knowledge about the Nursing and Midwifery Board of Australia’s approved practice areas, I will risk not getting a practice license as a registered nurse. NMBA offers practice licenses for professionals who have fulfilled the specialty and general requirements because they are competent and experienced in delivering quality nursing care to patients. I will mitigate this risk by participating in workshops conducted by NMBA to equip healthcare providers with vast knowledge about the Council’s specialty and general requirements (Hodge & Varndell, 2020). More so, workshops will allow me to engage in interpersonal and inter-professional collaborations while interacting with experts and work colleagues. Such experience will empower me with more knowledge and skills to improve my specialty and general practice in clinical settings. In addition, the current situation in Australia is that more knowledge about NMBA’s approved practice is needed in their pursuit of registration. As student nurses, there is a need to demonstrate efficiency with interprofessional collaborations to address the patient’s complicated health conditions like cancer, diabetes, and heart disease. Due to inconsistent interprofessional collaborations, registered nurses need to effectively implement specialty and general nursing practices due to minimal knowledge about NMBA’s nursing practice areas (Cooper, 2020).

Reviewing content on the NMBA website and reading articles from Medicine and Health databases such as BMJ Best Practice, Cochrane Library, and Australian Medicines Handbook are possible resources I will use to address this learning need. These resources offer vast information about specialty and general nursing practices. I can access and read the theoretical information about this learning area with an internet connection, smartphone, and laptop. It will take me three months, from May 1, 2023, to July 31, 2023, to address this learning need (Cooper, 2020). This period ensures I can improve my theoretical knowledge and clinical competencies in critical care and geriatric nursing to be registered with NMBA.

In conclusion, as a registered nurse, I have opportunities to improve my learning needs and professional development. I have succeeded in my nursing roles, particularly by improving patients’ well-being and health through peri-operative nursing. Despite this success, three learning needs derailing my professional development efforts, which I look forward to addressing to achieve my desired success. Minimal knowledge about the Nursing and Midwifery Board of Australia’s approved practice areas, transcending for my patients and fellow work colleagues, and being too self-critical are my learning needs. These learning needs will be addressed through personal research, attending seminars, and seeking behavioral therapy to improve my emotional intelligence, competencies, and experience in delivering quality specialty and general care. These efforts will cover three months between May 2023 and July 2023 to boost my chances of getting registered by NMBA.

Butler, J. (2023). Emotional Intelligence in Nursing Leadership: Clinical Update . ANMJ. https://anmj.org.au/emotional-intelligence-in-nursing-leadership-clinical-update/

Cooper, M.K. (2020).  Australian Regulatory Requirements for Migration and Registration of Internationally Qualified Health Practitioners  (Doctoral dissertation). https://digital.library.adelaide.edu.au/dspace/bitstream/2440/130112/1/Cooper2020_PhD.pdf

Hodge, A., & Varndell, W. (2020). Professional Practice. In Professional Transitions in Nursing  (pp. 42–78). Routledge.

Hodge, A., & Varndell, W. (2020).  Professional transitions in nursing: a guide to practice in the Australian healthcare system. Routledge.

Kaihlanen, A.M., Haavisto, E., Strandell‐Laine, C., & Salminen, L. (2018). Facilitating the transition from a nursing student to a Registered Nurse in the final clinical practicum: a scoping literature review. Scandinavian Journal of Caring Sciences, 32 (2): 466-477.

Kenny, A., Dickson-Swift, V., McKenna, L., Charette, M., Rush, K.L., Stacey, G., Darvill, A., Leigh, J., Burton, R., & Phillips, C. (2021). Interventions to support graduate nurse transition to practice and associated outcomes: A systematic review. Nurse education today, 100 : 104860.

Lindfors, K., Flinkman, M., & Kaunonen, M. (2022). New graduate registered nurses’ professional competence and the impact of preceptors’ education intervention: a quasi-experimental longitudinal intervention study. BMC Nurs, 21 : 360.

Lindfors, K., Kaunonen, M., Huhtala, H., & Paavilainen, E. (2022). Newly graduated nurses’ evaluation of the received orientation and their perceptions of the clinical environment: an intervention study. Scand J Caring Sci, 36: 59-70.

Nursing and Midwifery Board of Australia . (2016, June). Registered Nurse Standards for Practice. Retrieved March 8, 2023, from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx

Rush, K.L., Janke, R., Duchscher, J.E., Phillips, R., & Kaur, S. (2019). Best practices of formal new graduate transition programs: An integrative review. International Journal of Nursing Studies, 94 : 139-158.

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