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Challenges faced by student nurses in their transition to registered nurses

A transition from student nurse to registered nurse (RN) can be terrifying (Woo & Newman, 2019). They are suddenly pushed in a role where the patients are counting on them to care for them. After qualifying the graduate exam and interview, the student nurse enters the first day of working. They have a nametag of registered nurse, their dress-up looks to be a part however they do not feel it. During the initial months of being RN, many student nurses feel Imposter Syndrome (Ette, 2020). Even after having all the requirements for that position, they are frightened of being exposed as fraud and have doubts in their professional skills. They face challenging and unfamiliar situations for which they are not prepared to handle. Preceptorship and the orientation program may play effective role in their transition. Student nurses should be assigned a preceptor since the first day at work. The orientation program should include multiple aspects like clinical competencies, simulation and classroom timings to address the unique needs of each student nurse.

Generally, the orientation programs often lack individualization, consistency and follow up with new student nurses (Macdonald & Baker, 2020). The short-staffed organizations expect the new nurses to join and start working in their professional role in a very short amount of time. There are high expectations from new student nurses and when they do not meet those expectations, they develop guilt and failure. On joining the work, they receive just an abbreviated orientation and are expected to take care of patients as full time RN. Such an experience makes them incompatible and sets them for failure in their job role. They are unprepared and get easily frustrated with real time responsibilities. A study by Hampton, Smeltzer & Ross (2021) showed the turnover of new nurses leaving the organization during the first year of joining is 35-60%. Replacement of new nurses may cost an organisation about $80,000 to $90,000. The Organisations should provide them multiple opportunities to grow and practice in a professional way. In UK, there is a wide shortage of registered nurses and that is because there is inadequate training of nurses to meet the increasing demand for care of aging society (Kaihlanen, Haavisto, Strandell-Laine & Salminen, 2018). Also, there are inadequate measures to retain the old registered nurses in sufficient numbers. Therefore, it is important to support the student nurses during their transition towards registered nurses. They face stress in moving from role of student nurse (who is protected) to the role of registered nurse who is professionally responsible.

The aim of this literature review is to analyse the professional transition from student nurse to registered nurse. The review will investigate the transition process identifying common themes related to experiences of student nurses in their initial period of career as RN. The SWOT analysis will explore the common personal weaknesses towards satisfying career as RN. It will also find out the measures that can be taken to improve the condition. The study will provide an action plan to implement after completion of nursing courses.

Impact of the transition on professional growth

According to Ford (2022), few student nurses at UK feel that they are being used as a pair of hands for assisting the areas which are short staffed. Being on placement this harness them from utilizing the learning opportunities, hampering their supernumerary status. Prior to covid pandemic, there was already a shortage of 5000 nurses in UK, and still the system is coping to bridge the gap. A survey conducted by Nursing Times in January 2021 found that 80% of nurses feel that the safety of patients is compromised due to acute staff shortage (Ford, 2022). At paediatric ICUs, the healthcare assistants work as specialised nurses in 29 out of 30 specialist units of Britain to maintain the adequate staffing levels (Campbell, 2022). 

During their graduation courses, the student nurses are supported by the registered nurses and protected by supernumerary status (Christensen, 2016). However, after completion of course they are suddenly expected to act like competent registered nurses working in challenging environments with heavy workload, demanding care and immediate attention for critical patients. They are lacking their clinical skills, and knowledge. Sudden burden of responsibilities as registered nurse, causes emotional exhaustion, uncertainty in their own abilities and high level of stress. Kramer (1974) identified the transition of student nurse to a registered nurse as a reality shock. He identified four stages in this transition: (1) during initial honeymoon stage, the nurses are optimistic about their role and are quite excited. (2) When the newly qualified nurses become aware of their real professional challenges and responsibilities, it poses a reality shock for them. In this phase they feel stressed, confused and unprepared for their role. Nurses need support to move across the reality shock phase. (3) During third recovery phase, the nurses understand the real challenges of clinical settings and feel stable to improve their proficiency. (4)The last stage is resolution stage where the newly qualified nurse become confident about her role as a registered nurse and effectively contributes to the nursing practice (Duchscher & Windey, 2018). Theory of transition shock emphasizes on responsibilities, roles, knowledge and relationships that influence the transition from early stage of professional role in student nurses (Duchscher, 2009). It imposes the need of preparatory theory for transition of role and influences the need of undergraduate curriculum to bridge the rising expectations of the workplace.

According to Christen (2016), the imposter syndrome may be associated with transition of student nurses to registered nurse. The feeling involves fear and self-doubt. In these situations, the role of mentor is significant in final clinical practice to guide the students in professional growth and clinical learning process (Kaihlanen, Lakanmaa, & Salminen, 2013). To reduce the transition related challenges, many healthcare organisations implement transition to practice programs which include residencies, preceptorships and orientations (Hampton, Smeltzer & Ross,2021).

The main challenge for the nurse students is to construct a new professional self that combines the education attained with the realities of nursing practice. SWOT Analysis provides a tool to examine the growth of my career during transition from student nurse to registered nurse and the internal and external factors affecting it. This analysis will help me identify my weaknesses and to improve them. It will help me identify the potential threats that I can turn into opportunities. Hence, I have taken this SWOT Analysis to prepare professionally and personally for the upcoming transition from student nurse to registered nurse. The results of SWOT analysis have been compiled from the feedback taken from the family and friends, and my personal critique. The SWOT analysis can be taken as an background for the literature review. I have found certain issues that impact me in my performance. I become nervous many times while performing the given tasks and do not seldom ask my colleagues. It creates a confusion, as I prefer to do the tasks on my own rather than taking help of my friends. I may get very aggressive sometimes and impatient. I have been average student throughout my academics, I have been less social and connected with my friends. I have been self-centred most of the times, which made me self-confident. But weakened my social connections. I am not confident of practical tasks sometimes and get frightened easily getting cautious about my colleagues’ reactions. My mentors have noticed this thing and asked me to develop patience and take time in doing the tasks rather than getting nervous and confused. 

Strategies to improve competence and confidence

Though I have a good communication power, I have a tendency of repeating the same sentences many times. My voice is clear and word choice is also good however I have to work on my repetition habit to make my statements meaningful and effective for the listeners. I would like to improve my leadership abilities and deal with the situation in calm way rather than getting anxious.

My strengths include politeness, actively listen to the concerns of others, and being positive in my approach towards dealing with the issues. I am empathetic for the juniors and any person who approaches me. I think this ability would be helpful in caring for the patients. I have been good participant in a team. So, teamwork is also one of my strengths.

Emotional resilience and management of anxiety would be helpful in my transition towards a registered nurse (Choudhury, 2019). I need to develop self-awareness, understand my internal feelings and how they contribute to my actions. I have to develop commitment and consistency in keep trying to maintain the motivation. Flexibility in thinking has to be very important part of mental health that contributes to optimism, rationality and adjustability in any circumstances. Emotional resilience also depends on effective interpersonal relationships. It is important to improve our existing relationships and be open to make new relationships. 

I have found that I need to become more positive in my thinking and more resilient when I get aggressive and have anxiety. At few instances, I have seen that when I am unable to control my emotions, I get at the risk of burnout. I feel working with other members of the team can give me valuable opportunity to develop stability in my emotions. This literature review will help me identify common themes which I can use to understand the common issues that may take place in practical settings and the opportunities that may be available to make my transition from student nurse to registered nurse, successful and smoother. 

A search strategy involves organised group of key terms that can be used to search the databases (Dudley, Frolich & Robinowitz, 2014). It brings out correct results based on key concepts of research topic. In nursing, the research is considered important as whole of the nursing practice is based on evidence-based knowledge. Also, the nurses use research to upgrade their own level of knowledge and skills. A broad range of databases are searched to retrieve the most relevant and effective articles on the selected topic. The search is based on clear research question and initially all the gaps in the knowledge are identified. The SWOT analysis also revealed that the search would be based on transition between student nurse to registered nurse and their experiences.  The search strategy should be detailed and explicit, so that it reproduces same results using same methodology (Atkinson & Cipriani, 2018). It improves the accuracy and reliability of the review.

Formulation of research question is necessary before beginning any research. The research question identifies any existing uncertainty and aims to conduct a detailed investigation. Hence is is highly important to design a good research question. A good research question may be formulated using the acronyms FINERMAPS which stands for feasible, interesting, novel, ethical, relevant, manageable, appropriate, potential value, publishable and systematic (Ratan, Anand & Ratan, 2019). Developing the research question involves identifying the subject and perform preliminary research over that subject. Narrowing down the scope and focus of the research question, a research question is framed and evaluated. In healthcare and nursing the systematic production of information may be useful to promote, restore, maintain and save the health of people. Research plays primary role in development of new health policies and clinical practices. Therefore, a logical scientific approach is required to generate new claims in healthcare research. Most effective research topics are carefully defined and narrowly focused however they are an important part of the complex and broader problem.

Transition theory

My literature review is based on research question: Is the transition from student nurse to registered nurse is challenging and complex? 

The aim of this literature review is to identify the factors or conditions which make the transition of student nurse to registered nurse challenging and stressful. The research also suggests how we can improve the condition. 

Literature search is done using large set of digital academic databases (CINAHL, PubMed, Proquest, Biomedical and PubMed Central). These databases involve wide range of peer reviewed credible, and reliable research articles in nursing, clinical, medical and research (Hopia & Heikkila, 2019). CINAHL provides a wide range of nursing literature in form of journals, books and news articles. Proquest gives access to wide range of study material in form of government websites, newspapers, e-books, dissertations, historical collections, periodicals etc (Proquest, 2022). The biomedical database is considered best source information to perform quick search. Biomedical includes more than 23000 scientific and academic journals, 9000 websites, integrated search across multiple other databases, 110,000 conference papers and 23,000,000 patents (Masic & Milinovic, 2012). 

For searching the articles, general broad range keywords were used initially which involved student nurse, transition and registered nurse. Initially the records were identified after searching the databases. Then the duplicates were removed and remaining records were screened for title.  Many articles got excluded on the basis of title. The remaining studies were screened for the abstract and multiple records were excluded after the review of abstract.  The full text articles were assessed after the search was narrowed down using inclusion and exclusion strategy. The articles published from 2014 to 2022 and published only in English language were retrieved. The articles that were peer reviewed and available in full text were retrieved. The studies for which full text articles could not be retrieved within the provided timeframe were also excluded. The articles published in the period other than 2014-2022, Non-English articles were excluded. The articles that had abstracts only, secondary studies, grey literature, and those not published in a peer review journal were excluded. 

The geographical restrictions were not applied to the studies so the retrieved articles are taken from a wide range of countries without any constraints (Seton Hall University, 2022). The Boolean operators like AND, OR and Truncation asterisk are put between the keywords to retrieve the more focused results. The search identified only primary sources of literature are accessed. According to Parahoo(2014), the primary sources of literature provide original source of information collected directly from the researchers. It reduced the chance of redundancy and misinterpretation of studies. The results of the search were reviewed to remove the redundant or duplicate studies. The abstract and the conclusion was studied to identify the relevance of the collected studies. 25 articles were found finally out of which only 8 were found fit after complete analysis. These 10 articles were critically appraised using CASP checklist tool.  Six themes emerged from the information collected from these studies: Professional Growth, Transition Challenges, Feeling Supported, Transition Shock, Reflections and Role of Mentor. 

SWOT analysis

The CASP tool helped evaluate the strengths and weaknesses of each article and find out which study would be more effective for literature review (CASP, 2022). The appraisal provided detailed relevance of each article based on 7-10 checklist questions. It is identified that most of collected studies are qualitative. In nursing the qualitative studies are highly relevant as they provide a method to understand the phenomenon and the processes which are aimed at identifying the essence and cause of the problems in detailed manner. The information collected depends on the real time experiences of the people.  After the critical appraisal was complete using the CASP checklist, 10 articles were selected for the literature review. 

The table summarizing the search strategy is as follows:

Database

Search Terms

Inclusion

Hits

Articles Found

Articles Used

CINAHL

(Student Nurse OR Newly Qualified Nurse) AND Transition AND Registered*

-full text

-2014-2022

-peer reviewed

-English language

85

5

3

Proquest

Graduate Nurse OR Student Nurse AND Transition AND Registered Nurse

-full text

-2014-2022

-peer reviewed

-English language

20

4

1

PubMed

(Student Nurse OR Newly Qualified Nurse) AND Transition AND Registered*

-full text

-2014-2022

-peer reviewed

-English language

65

5

4

PubMed Central

(Student Nurse OR Newly Qualified Nurse) AND Transition AND Registered*

-full text

-2014-2022

-peer reviewed

-English language

56

5

1

BioMedical

(Student Nurse OR Newly Qualified Nurse) AND Transition AND Registered*

-full text

-2014-2022

-peer reviewed

-English language

75

6

1

According to Darvill, Stephens & Leigh, (2022), transition may be defined as ‘the passage of life from one phase to another, involving the timespan, processes and the perception’. The transition involves demands and changes for us. It involves how we respond to it. The transition from student nurse to a registered nurse involves temporary timeframe of adjustment and changes. The first anticipation of change causes the transition which remains until the stability is attained in the new status within a particular period of time. The period of transition involves three phases. The first phase is separation, where the person separates from his pre-existing social position. It causes the feeling of excitement and happiness. The next stage is transition (0-6 months) which involves appropriating the rituals and customs of new position. It involves a feeling of rejection and shock. The third stage involves incorporation (>12 months) where the person may take up his new role and identity, and then is accepted by the group. It involves gradual acceptance and proficiency of skills and knowledge.

A newly qualified nurse, may doubt her abilities, show lack in confidence. It is necessary to understand that we are no new to this feeling. All the new nurses feel lack of confidence in their initial role.  When preparing for the transition, the student nurse may set certain goals that she wants to achieve, and may discuss them with the preceptor or mentor. Even though gradually you develop the skills to care for the patients however the registered nurses need to maintain good relationships with the colleagues and consistently discuss and seek assistance from them. It helps you identify that you can work independently and your knowledge and skills are continuously advancing. However, you can still get assistance from others.

The literature review collected final ten articles which can be summarized as follows: 

S.No.

Title/ citation

Study Design

Theme

1

Darvill, A., Stephens, M., & Leigh, JA. (2021). Transition to nursing practice : from student to registered nurse. (2nd ed.) (Transforming Nursing Practice). Sage Publications. https://uk.sagepub.com/en-gb/eur/transition-to-nursing-practice/book273776#contents

Qualitative Analysis

1

2

Kaihlanen AM, 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. Scand J Caring Sci. 2018 Jun;32(2):466-477. doi: 10.1111/scs.12494. Epub 2017 Aug 22. PMID: 28833325

Literature review

2

3

Spector N, Blegen MA, Silvestre J, et al.(2015)  Transition to practice in hospital settings. J Nurs Regul. 2015;5:24–38

Qualitative study

2

4

Whitehead B, Owen P, Henshaw L, Beddingham E, Simmons M. (2016) Supporting newly qualified nurse transition: A case study in a UK hospital. Nurse Educ Today. 2016 Jan;36:58-63. doi: 10.1016/j.nedt.2015.07.008. Epub 2015 Jul 26. PMID: 26254674.

Case Controlled study

3

5

Hampton KB, Smeltzer SC, & Ross JG. (2021) The transition from nursing student to practicing nurse: An integrative review of transition to practice programs. Nurse Educ Pract. 52:103031. doi: 10.1016/j.nepr.2021.103031. Epub 2021 Mar 19. PMID: 33773484

Literature Review

2

6

Duchscher, J. & Windey, M. (2018). Stages of Transition and Transition Shock. Journal for Nurses in Professional Development. 34(1). 228-232. DOI:10.1097/NND.0000000000000461

Phenomenology research

1

7

Christensen M, Aubeeluck A, Fergusson D, Craft J, Knight J, Wirihana L, & Stupple E. (2016). Do student nurses experience Imposter Phenomenon? An international comparison of Final Year Undergraduate Nursing Students readiness for registration. J Adv Nurs. 2016 Nov;72(11):2784-2793. doi: 10.1111/jan.13034. Epub 2016 Jul 5. PMID: 2724017

Survey Design

3

8

Mårtensson G, Löfmark A, Mamhidir A, Skytt B. (2016) Preceptors' reflections on their educational role before and after a preceptor preparation course: a prospective qualitative study. Nurse Educ Pract. 2016;19:1–6

Prospective qualitative study

2

9

Woo, M., & Newman, S. A. (2019). The experience of transition from nursing students to newly graduated registered nurses in Singapore. International journal of nursing sciences, 7(1), 81–90. https://doi.org/10.1016/j.ijnss.2019.11.002

Mixed Method study

1

10

Kumaran S, Carney M. (2014). Role transition from student nurse to staff nurse: facilitating the transition period. Nurse Educ Pract. 2014 Nov;14(6):605-11. doi: 10.1016/j.nepr.2014.06.002. Epub 2014 Jun 21. PMID: 25001181.

Case controlled study

2

Investigating the literature review, three themes have emerged from the information collected from these studies:

i. Professional Growth and Challenges,

ii. Feeling Supported in Transition Shock,

iii. Reflections and Role of Mentor.

The initial six months are considered critical for the professional adjustment of newly appointed student nurse. The experience of transition acts as a decisive factor in driving their commitment towards the career as a potential nurse. The existing support system for transition practically does not match, supports and reflects the expectations and requirements of new nursing students. Negative feelings give rise to professional dissatisfaction and disillusionment in career. The changed professional relationships and identity causes stressful experience at personal level. The student nurse first moves out of her initial comfort zone, then they shift to new working environment where they have to take greater responsibilities and accountability. They have to manage unfamiliar responsibilities and consequently which increases stress.

They reported lack of experience which triggers most of the stress level. Many nurses feel difficulty analysing the diagnostic and laboratory investigations. Their practical knowledge is inadequate to do this and hence the nurse do not feel confident in analysing the reports. They are expected to perform the clinical skills independently without any other assistance. Not everything that is practiced in ward, is taught at school. But the nurses are expected to know everything. Just 53% nurse students feel competent in managing the load of work that is assigned to them (Darvil et al., 2021). They are expected to work in an efficient manner. Thus, the professional growth is not faster or straight but involves lot of ditches and loopholes.

On the other hand, the student nurses who manage to sail through this transition phase, attain stability and professionalism in their nursing practice. The transition and all the different challenges make the nurses more competent and better equipped to address the scenario.

The new nurse students feel difficult to mix up with the experienced colleagues as they use harsh tone of communication  towards them, when they begin teaching the operating theatre is very much stressful. It appears that the experienced colleagues always put orders on new graduates. Their way of talking is not casual but more like questioning. The unfriendly organisation culture with less desirable workplace was also reported due to formation of cliques among the senior colleagues. If there are any personal differences among the factions, it would be reflecting in the official duties. Racial cliques are also formed where the members talk in their local languages (Simpson, 2022). It develops language barriers among the rest of the staff. The student nurse is considered as lowest in the working environment. So, it is advisable to have patience while being on transition phase. It is better to correct the lack of knowledge whenever you feel that, by saying, I don’t know. After that you can actively seek out the knowledge and apply it.

At the nursing schools the students are taught about different disease processes and related care in nursing. The nurse students apply their knowledge on the clinical care of real patients. However, there are challenges in the clinical education which impede the student nurses from getting benefit of all the training components. The challenges include lack of clinical sites to achieve adequate experience, consistent movement from one clinical site to another and increased student to trainer ratio. The nursing facilities provide nursing practice for large number of student nurses, it is equally important to care for the patients. Initially the students are given task of caring for only one stable patient at a time. After that when they begin the career as newly graduated nurse, they have to provide care for complex cases in huge numbers. In addition, they also take care of organising their daily tasks like documentation, answering the calls, advocating with the patients, working with the interprofessional teams and the family members. Therefore, the role of student providing care for just one stable patient is very different from the role of practicing nurse who performs same care every day. The professional role of nurse leads to transition shock, incompetence and anxiety when the new nurses face the real time situations of their nursing practice.

Majority of the nursing programs do not prepare them for the specialist critical care areas. The Institute of Medicine has identified the need of programs like ‘Transition to Practice’ (TTP) for the new student nurses. More than 25% of student nurses leave their job as a newly appointed nurse within 1 year of nursing practice (Kumaran & Karney, 2014). It increases considerable burden of cost for the nursing facilities. Therefore, there is need to reduce turnover and improve the quality of TTP period. In a survey of 5700 nurse students, only 10% were assessed to provide completely safe patient care (Kumaran & Karney, 2014). The newly appointed graduates make more errors and are involved in more negative safety approaches. It is identified that the programs or interventions like TTP provided by National Council of State Boards of Nursing, are successful in lowering down the turnover rate to 14.7% in comparison to the hospitals which had no structured curriculum based TTP (25%) (Specter, Blegen & Silvestre, 2015).  The interventions provided safety and quality education, communication and teamwork, informatics and evidence-based practice. Such programs should essentially be of 6 months period or more.

There is a need of Continued Professional Development and quality level preceptorship program, so that being on placement the student nurse can practice and learn. The student nurse will be provided support by the experienced practitioner who can be named as their preceptor. He can guide the student nurse in fitting in new role of RN , gain confidence and extend their support whenever they need. According to Nursing and Midwifery Council, every nurse should have atleast some period of preceptorship. There should be specific time for the preceptees and preceptors, their selection and preparation, and the structure of management to help the preceptorship process. According to a study by Whitehead et al.(2016), preceptorship is greatly valued by 85% of preceptees. The preceptors play essential role in reducing the stress level in this challenging transition. The process positively affects the preceptees in improving their clinical and communication skills.in addition to personal and professional development. The program is evaluated as positively affecting the student nurses in their sustainability, value and impact and engagement.

The preceptors conduct formative assessments and collect feedback of nurse student’s performance and identify the further possibilities of improvement. Through reflections, debriefings and discussion, they help the new student graduates formulate the patient care options, develop reasoning and thinking skills (Martensson, 2016). Through open ended questions the preceptors encourage high level thinking and link the current experience with the previous one. The other strategies may include modelling of role, promote dialogue, build on earlier experience, practice by providing clinical scenarios. Though the preceptors can help improve the nursing practice of new graduate nurse students, the preceptors are not considered as teacher educators as they lack pedagogical skills and competence of an expert teacher. The nurse preceptors may be educated for effective teaching and feedback approaches, learning styles and adult learning theory. The nurse preceptors have significantly reported that they are not prepared for their role as preceptors, they have low confidence in training the new graduate nursing students (Nielson & Lasater, 2016).

Entering the professional practice after leaving the nursing school may be a transition shock for the nursing students (Kaihlanen, 2018). The new nurse students learn several aspects of patient care, this period is known as reality or transition shock for them. There are considerable differences in perceived knowledge as student, and they are confronted with change sat the level of physical, developmental, sociocultural and intellectual and emotional stage. During the first four months, the student faces professional and personal adjustments (Simpson, 2022). After the completion of orientation phase, the isolation and exhaustion resulting from doubt ridden and disoriented mind, while facing a new reality that was unexpected. The traumatic adjustment is associated with inadequate emotional and functional assistance, insecurities in discussing the doubts with seniors, lack of support, and unrealistic expectations in performance by the hospitals. The fears of new nursing students during the transition shock involve they should not be identified as clinically incompetent, they could fail in providing care for the patients and some mistake may cause harm to the patient, and they would not be able to cope with the responsibilities and roles assigned to them. Many times the new nurse graduates are deemed incompetent by their peers which further deepens their feeling of disguise.

The new student nurses feel loss of support system when they join the clinical setting (Woo & Newman, 2019). They are no in immediate access to their earlier educators, creating self doubt and isolation. Most of their new graduate colleagues work in different shifts or have located to other places.  In ongoing professional development, the access to peer support is considered an important factor. The nursing students also have problems in maintaining the standards and intentions in nursing practice, which they had developed during their nursing education.

Physically the whole energy of the day is exhausted in meeting the requirements of new job role without speaking about difficulty level (Parker, Giles, Lantry & McMillan, 2014). The changes in lifestyle on getting a job involve advancing the relationships, purchase of home or cars, modified living arrangements which act as unexpected burdens and distractions. They are not sure about what the successful transition would be looking like. The lack of any normalizing feedback and demands of adjusting to the shift work, increases insecurities and doubts.

During the initial four moths they work in very hypersensitive stage and experience all kinds of tremors, disrespect, disapproval (Parker et al., 2014). The combined result of this initial stage was the development of a mature professional self. They transformed the manner in which they have been looking after themselves. The low levels of self confidence made them less interested in talking to the senior nurses and physicians. Their behaviour was more hierarchical and aggressive style of communication rather than based on college relationships.

The new student nurses need to understand that initially they have to apply their skills in a way compatible to state and organisational regulations and standards (Parker et al., 2014). The nurses can begin improving their skills from the very beginning to reduce the negative impact afterwards.  The nurse students have to improve their skills in patient care and also in administrative skills. It will improve their confidence and satisfaction in the new job role. The student nurses are advised to consult and talk regularly with the senior nursing staff to keep updated about policies and working contexts. The healthcare plans and treatments keep on changing on regular basis and we depend on each other to deliver most effective and safest care.

If the speciality unit that is provided to the student nurse does not make her comfortable to work, it is necessary for the student nurse to discuss her concerns with the nursing management so that they can take mutual decision to let you shift to the other setting or quit (Damion, 2022). It is common to switch the specialities within the first six months of joining as student nurse.

Reflections involve helping the student nurses develop clinical competencies and skills while  they are at a practice in clinical setting (Kelly, 2019). Reflecting on their own experiences, the student nurses can become familiar with multiple situations and can identify their role in those conditions. The students can assess their own role, beliefs, behaviors and actions. The reflections help the nurse students develop flexible holistic and individualised approach to patient care, make them effectively capable of resolving the real time issues, apply systematic reasoning and monitor their own competence. The reflections may also include formal dialogue between the nurse student and the supervisors which help them develop valuable competencies based on their emotions, thoughts and experiences and incidents faced by the nurses in clinical practice.

While involving in reflection with the clinical supervisor, the student nurses can develop competencies in terms of thoughts they face during their clinical practice, the emotions and experiences they encounter related to incidents faced by them on daily basis (Schumann, 2017). The tools used in reflection interventions by different level of nurses during their educational course are different to the tools used in clinical placement. Therefore, the role of mentor is highly relevant during the transition phase to help the nurses use appropriate level of reflection tools on the basis of their education and experience.

The mentor can assist the nurse student in the transition by supporting in change. The actions of mentor when positive may act as reinforcers and boosters for morale while at the same time negative expressions and actions pose difficulty to cope with transition associated challenges. The qualities of mentor also influence the professional growth of nurse students. They learn leadership, calmness and positivity of attitude making the transition satisfying. Mentors may be great source for the new nurses as they can ask questions to mentors in comfortable manner (Schumann, Peters, Meinertz & Anna, 2018). Mentor can fill the gap of uncertainty in the mind of nurse students by assisting them understand the workplace culture, making them aware of the new policies and procedures, and managing their workload (Erikson, 2018). Students may benefit from the expertise, network, ideas and wisdom of mentors providing them encouragement and guidance during stressful phase of transition.

The findings of collected studies agree with each other. All the identified studies agree that the nurse students face challenges and stressful conditions when left with high burden of responsibilities at their initial role of working as a registered nurse. The study by Whitehead et al (2016) investigated the cause of distress and challenges faced by the nurse graduates in their professional role. The study identified significant level of distress among the nurses as assessed in paediatric ward. The nurse students working against their personal expectations and beliefs caused the stress. It was mainly when they were dealing with conflicting situations among the peers working with them.  The high workload, uncertainty in results and emotional exhaustion influenced the sufferings of the nurses. The nurse students who completed initial 6 months of time at the setting, had a feeling of accomplishment and it increased their resilience level. In the study by Dudley, Frolich & Robinowitz (2014), the nurses are recruited from high intensity settings like ICU and paediatric wards which may not be representative of the general workforce of nursing graduates. Therefore, it is necessary to conduct further research to involve the nurses from multiple settings. Choudhury (2019) found that few nurses at the ICUs and critical care wards suffer from post traumatic stress disorder, depression and anxiety. The nurses students which had better levels of resilience skills had stronger spiritual beliefs. The study by Hampton, Smeltzer & Ross (2014) found that the future expectations and perceptions of nurse students were largely responsible for the causing burnout during the transition phase. The nurse students who completed the transition phase successfully and were experienced now, had developed improved resilience levels and very low level of emotional exhaustion. Thus, it is clear that the training courses which helped the nurse students develop resilience in them, made them less susceptible for leaving the job post. The new student nurses are at higher risk of leaving the job. Development of resilience among the student nurses can help the organisations prevent the increasing burnout and improve the overall satisfaction in the work performance. Mindfulness trainings, relaxation and reflection in own practice are effective strategies to develop resilience among the nurses.

Several interventions are being implemented at the healthcare organisations to ease the transition experience for the nurse students. Hampton (2020) studied the outcomes of such interventions which can have positive impact on job retention and satisfaction levels. The study found the need of standard concepts and instruments to assess the successful transition of nurses from student to nurse stage. The study analysed the role of socialization, support, professional growth, feelings and transition shock to make them prepared. The study identified that transition programs though conducted by the healthcare organisations, in form of preceptorship and orientation. The student nurses still do not find them effective and they still feel the risk that they would not be able to clear the transition phase successfully.

The study by Missouri Nursing Student Association (2022), recommended the strategies to improve the process by encouraging more talk with preceptors and seniors. The student nurses should not hesitate in asking if they don’t know anything. The student nurse need to utilize the available resources by staying connected with pharmacy, laboratory, google, and open discussions with the co-workers and physicians. The co-workers and peers may be more taken as a team and carry on the process day by day. The nurse students also need to maintain self-care during the work and address the concerns if any affecting you, with priority. It is important to maintain the self confidence and trust the education we have attained.

A cohort study by Christenses et al (2016) involved 223 final year students. It found positive association between the readiness for nursing practice and the imposter phenomena.  The role of mentor in this professional transition is helpful as an open resource for the student nurses and help them in their concerns and questions. The mentor can help the students in finding ways to big goals of career and should not be only limited to day to day operations (Johnson, 2018). The mentors may encourage healthy teamwork and working environment by providing induction period to the student nurses, by conducting regular interviews and meetings with the nurse students and collect regular feedback from the student nurses (Pramila, 2020). The role of mentor may reduce the anxieties involved in transition phase and can make the path smooth for the nurses.

The short-staffed organizations expect the new nurses to join and start working in their professional role in a very short amount of time. There are high expectations from new student nurses and when they do not meet those expectations, they develop guilt and failure. On joining the work, they receive just an abbreviated orientation and are expected to take care of patients as full time RN. Such an experience makes them incompatible and sets them for failure in their job role. They are unprepared and get easily frustrated with real time responsibilities. A study by Hampton, Smeltzer & Ross (2021) showed the turnover of new nurses leaving the organization during the first year of joining is 35-60%. Replacement of new nurses may cost an organisation about $80,000 to $90,000. The Organisations should provide them multiple opportunities to grow and practice in a professional way. In UK, there is a wide shortage of registered nurses and that is because there is inadequate training of nurses to meet the increasing demand for care of aging society (Kaihlanen, Haavisto, Strandell-Laine & Salminen, 2018). Also, there are inadequate measures to retain the old registered nurses in sufficient numbers. Therefore, it is important to support the student nurses during their transition towards registered nurses. They face stress in moving from role of student nurse (who is protected) to the role of registered nurse who is professionally responsible.

The action plan offers specific goals and achievements that may be accomplished in given time limit. This action plan is based on SMART goals to have the targets achievable and measurable, specific, realistic and time bound. The action plan may be used as  a preparatory document for me as I complete my placement and begin my practice as a graduate nurse. To improve my resilience, I would work to improve my lifestyle during the upcoming placements. I think improving the lifestyle would help me change complete living approach and may turn my personality as active and energetic. I would be able to help others only when I would be healthy and sound in my health. So caring for my physical, mental, emotional well being would be an effective step towards resilience and winning over the transition shock.

I would be ready and prepared to learn. I would join a mindfulness or relaxation course to improve resilience abilities. I would improve my lifestyle for example I would improve my sleep to 8 hours compulsorily, I would take nutritious meals on time without skipping the breakfast. I would include fruits vegetables and water in my daily routine. I would also make a habit of daily exercise in the morning to make myself ready for the upcoming transition phase. I would work on my communication skills to be more socialised and talking to everyone in the setting with a pleasant face.

I would try to accomplish skills like good communication skills, soft skills to which I could not accomplish during my coursework. I understand my strengths and weakness, so I would work on my weaknesses and try to improve them.

To the end of 12-month preceptorship program, I would be involved in real time experience of my placement. There I would be providing care for the real time patients under the guidance of supervisor. Initially I would work with the preceptor nurse while during the course, I would like to work more independently. I would always be respectful to my preceptor, asking and clarifying my concerns. At the end of everyday, I would ask the preceptor about her feedback and what areas I can improve. I would be ready to learn and would convey this to the preceptor, accepting his intervention and inputs with an open mind. Whenever during the placement I get stressed, I would take 3 minute deep breathing to alleviate it. I would practice to live in present moment each day rather than carrying forward the stressful memories of last day. During the off time hours, I would spend quality time with my family and friends, I may utilize my hobbies to enjoy in that free time. It would help me stay pleasant, pappy and contented in my role as a nurse.

To improve my critical thinking skills and problem solving skills, I would take time to think before acting aggressively.  I would practice thinking about how the two scenarios may be connected, and influence each other. I am sure practicing such mindful technique would improve my problem solving and cognitive skills.

Rather than taking my peers as my competitors, I would consider them as team mates and would seek their help and help them simultaneously working in collaboration in as a team. I am aware that the patients have different cultural sensitivities, I would be prepared to respect each cultural practice and belief of the patient. During the course I would learn how to do it in a practical way, under the guidance of learned senior registered nurse.

I have to be compassionate, polite and soft in my tone while communicating with patients and their families. I would take care of my communication skills, and my presentation skills to appear before the patients as a pleasant and cheerful being ready to help them. For this I will have to keep a close watch on my behavior.

I would like to improve my punctuality and time management skills. I will take help of calendar and fill the appointments and to do plans. Every week I would revise the list for each day of the upcoming week. During the documentation for the patients I would be very careful in writing down most accurate data.

I would attend the weekly meeting with my mentor sincerely without fail and would report all the concerns I met across during the week. I would understand the expectations and principles that the mentor would explain us. I would aim to have complete transparency with the mentor telling him all my concerns, issues and asking him any questions if I have.

For improving the patient safety and patient care, I would check during the bedside report, all the concerns associated with patient safety every day. I will develop to-do list for each of my patient and will complete the hourly round of every patient without any delay.

I would be aware of the location of crash cart, pyxis and other equipment just by the end of first week of preceptorship. I would independently provide correct reporting about the patients assigned by the end of second week. I would be providing total care for two patients, under the guidance of senior registered nurse and supervisor.

It is a good approach to keep weekly journal and keep track of meeting my objectives every week.

Conclusion

Though I have a good educational background and have been a good student throughout y nursing course, I feel that my transition to a registered nurse will not be simple enough and I would require emotional resilience in coping with the navigation issues. The studies retrieved in this literature review provided that the emotional resilience is highly valuable for lowering down the stress, anxiety levels, and post traumatic stress disorder.  The review provided detailed analysis of challenges that can appear during the transition in professional growth, the strategies which would be helpful in dealing with the transition shock, and the resources like preceptors  and mentors who can be helpful to reflecting in my clinical practice and in addressing the transition related stages.

I believe that improving my weaknesses (such as lack of emotional control, difficulty to accept change easily, lower level of resilience and coping skills and lack of self confidence) can empower me develop a better self. I have identified my strengths and would like to improve them to develop resilience.

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