For more than two decades, researchers have been examining the difficult role transition from the nursing student role to the professional nurse role (Phillips et al., 2014). This difficulty in transition has many contributing causes including lack of leadership support, bullying, role stress, role ambiguity (Phillips et al., 2014), excessive workloads, and workplace culture (Parker et al., 2014). This period of transitioning can lead to feelings of being overwhelmed, anxiety, exhaustion (Hofler & Thomas, 2016), and low confidence (Casey et al., 2004). The idea of “eating our own” has been consistently voiced throughout the history of nursing. The transition to the nursing role is intricate and complex.
In 2008, the National Council of State Boards of Nursing (NCSBN, 2008) developed a regulatory report for transition to practice programs. Then in 2011, the Institute of Medicine encouraged the development of transition to practice (TTP) programs. Following that development, the National Council of State Boards of Nursing developed a standardized TTP model (Silvestre et al., 2017). In 2018, the Academy of Nursing recommended that all new graduate nurses complete an accredited nurse residency program (Goode et al., 2018). TPP programs are also known as a nurse residency program or a new graduate nurse residency program. In the United States, numerous TTP programs were found that vary in length and structure, but the overall purpose was to help transition new graduate nurses into the practicing nurse role (Edwards et al., 2015; Letourneau & Fater, 2015). These TTP programs were geared toward the support and acculturation of the novice nurse into the workplace environment and culture.
A TTP program needs to measure outcomes. Many programs measured turnover and patient safety as a means of demonstrating outcomes (Silvestre et al., 2017). When examining turnover, programs needed to be able to identify what specific issues led to the turnover. Turnover can be related to urban versus rural hospitals, Magnet® versus non-Magnet, number of beds, and age of the nurse (Blegen et al., 2017). Other contributing factors included presence or absence of authentic leadership (Spence Laschinger & Fida, 2014; Spence Laschinger et al., 2015) and the strength of the institution's preceptor programs (Clipper & Cherry, 2015). The struggle was to identify and use tools that measure and identify what is causing the new graduate to leave the nursing profession.
The Casey-Fink Graduate Nurse Experience Survey (CFGNES) tool was one means in which organizations review the stressors of a new graduate and what specific issues the new graduate face (Casey et al., 2004). Two questions were raised regarding how well the CFGNES documents (a) the anxiety levels, and (b) the stressors encountered by a new graduate. This article sought to provide the results of a project that used this tool to identify anxiety and stressors within this population.
Two of the biggest obstacles that new graduates face are reality shock and transition shock (Clipper & Cherry, 2015). When these feelings are not addressed, new graduate nurses leave the organization and nursing profession (Duchscher, 2009; Hofler & Thomas, 2016; Parker et al., 2014; Spence Laschinger et al., 2015). Care must be given to ensure that the transition of novice graduate nurses is supported and accommodated. According to Fink et al. (2008), the new graduate nurse has trouble with role transition. Factors that affect their role transition include confidence, peer and preceptor relationships, work environment, organization and priority setting, and physician communication.
Numerous studies have examined the new graduate transition to assist in the identification of common issues. Phillips et al. (2014) stated that the most important factors in new graduate transitioning were support from the institution and respect from colleagues. Holfer and Thomas (2016) concurred, stating that without supportive relationships, the new graduate nurse may become overwhelmed and exhausted; and thus leave the nursing profession altogether. In a systemic review by Walker et al. (2016), one of the overarching themes noted was that new graduate nurses transition more successfully with organizational support, welcoming environments, and a gradual increase in workload. Other common themes that emerged from the systemic review that influence a new graduate's transition include work responsibilities (e.g., patient load and decision-making expectations), nursing culture (e.g., role discrepancy and witnessed unprofessional behavior), work readiness (e.g., orientation period and book versus real world nursing), and support (e.g., preceptor and organizational) (Walker et al., 2016). To address these over-arching themes that lead to transition shock, retention, and burnout, organizations need to develop a TTP program.
The theoretical basis for this project was the transition shock model. Duchscher (2009) developed the transition shock model to describe the journey that new graduate nurses progress through during transition shock. Transition shock is contrast between the new nurse graduates' roles, responsibilities, knowledge, relationships, and performance as a student versus now as a professional nurse (Duchscher, 2009). The constructs of the transition shock model are the physical, emotional, intellectual, and sociodevelopmental responses that new graduate nurses experience during the transitional journey from nursing student to professional nurse.
According to Duchscher (2009), the emotional responses from new graduates during this time were labile and intense. The anxiety and stress they experienced became overwhelming and physically debilitating. Higher levels of anxiety and stress were correlated with a lack of emotional support at work, insecurity regarding abilities and communication, and unrealistic expectations from either the new graduate themselves or the institution and/or colleagues (Duchscher, 2009). Physically, new graduates experience exhaustion. This exhaustion was due to changes in sleep patterns, physical demands of working 12-hour shifts, changes in life patterns, and sleeplessness (Duchscher, 2009). According to Duchscher (2009), the sleeplessness was related to all-consuming thoughts of the work day, the previous shift worked and decisions made, and anticipation of the next shift. New graduates learned how to trust in themselves in sociocultural and developmental ways, how to balance work and personal lives, how to become accepted in the nursing culture, and how to develop work relationships (Duchscher, 2009). According to Duchscher (2009), the development of work relationships and acceptance by colleagues were pivotal points in the new graduates transition from nursing student to professional nurse. Intellectually, new graduates experienced doubt and insecurity that stemmed from differences in theory and practice, lack of practical knowledge, and being placed in situations that exceeded the new graduates' comfort and knowledge (Duchscher, 2009).
One of the contributing factors to transition shock was the element of surprise in the contrast between academic expectations and responsibilities versus the professional nurse role (Duchscher, 2009). According to Duchscher (2009), the transition period was not a linear process and evolves throughout the first 4 months postorientation. At the end of the postorientation period, the physical, emotional, intellectual, and sociodevelopmental responses can lead to feelings of disorientation, loss, confusion, and doubt (Duchscher, 2009). According to Duchscher (2009), by understanding the emotional, physical, intellectual, and sociodevelopmental responses that new graduate nurses experience, organizations can plan for better ways to aid new graduate nurses in successfully transitioning into their new role.
Following the institutional review board approval by the agency, this project was implemented as a retrospective examination of all the completed CFGNES documents from the designated year (2018–2019). The survey was regularly administered at the beginning of the TTP program, following the completion of the simulation-focused learning process, and at the end of the direct supervision phase. The simulation components complemented the didactic presentations and included skills such as head-to-toe assessment, intravenous starts, nasogastric tubes, chest tubes, tracheostomy suctioning, and critical thinking scenarios. The surveys completed at the three time periods were used to see the changes recorded by the participants as they move through the TTP program. Although the original work done by Casey et al. (2004) reflected repeated testing at months 6 and 12, this study restricted the time line to repeated testing at the start of the TTP program (initial hire), and at 3 months (Independence Day [i.e., the day the intern is no longer assigned to a preceptor.]). Determining those stressors and anxiety levels related to this key period within a resident's progress toward competency on the nursing unit was critical in decreasing burn-out and dissolution within the nursing profession. Both graduate nurse interns and external hire graduate nurses were included in the CFGNES project. For this project, a graduate nurse intern was defined as a hospital employee who had completed the nurse intern program and graduated from nursing school. The intern program consisted of simulation, clinical, and didactic sessions over a total of three semesters while the employee was attending nursing school. Upon graduation from nursing school, the nurse intern transitioned into the nurse resident role. An external hire graduate nurse was defined as a newly graduated nurse who had not completed the nurse intern program.
Three research questions were used within this study:
What stressors are identified from the completed CFGNES?
Do the graduate nurses employed at Midland Memorial Hospital mirror the themes identified by the initial research generated for the CFGNES?
Does the use of simulation positively affect the anxiety levels for the individuals participating in the intern program?
The project was trying to establish the CFGNES as a means for assessing the trajectory of anxiety encountered by interns and residents as they transitioned into the nursing profession. The use of a tool to evaluate the stress and anxiety levels would be beneficial to developing avenues to confront the challenges resulting from higher stress and anxiety levels. By understanding the stressors encountered and identified by the interns and residents, programs and/or activities could be incorporated to address these issues during the intern and resident programs.
An acute care facility in western Texas conceptualized and implemented an intern program that transitioned into a nurse residency program. The intern program was established to allow nursing students to develop competence and self-efficacy with designated skills and tasks while still within a nursing program. After these students graduated, they were transitioned into the nurse residency program to further support and develop their competencies. Throughout these two programs, participants were supported with lectures, simulation activities, direct supervision, and indirect supervision.
All interns (N = 145) employed at the acute care facility completed the CFGNES as part of their intern program. This tool was completed at the beginning of the TTP program, at the end of simulation-focused learning, and at the time of their transition from direct supervision to indirect supervision. Because all identifying data were removed from the CFGNES prior to including the data into the study, all of the completed CFGNES tools for the 1-year period were included in the analysis.
The CFGNES has been characterized as a process for identifying the stresses and challenges from new graduate nurses to be able to address those issues and increase retention (Casey et al., 2004). In the original CFGNES study, the new graduates' confidence and comfort increased between 6 months and 1 year from the original start. The revised CFGNES contains five sections: “demographic information; skills/procedure performance (three open-ended questions); comfort/confidence (25 items with Likert scale response with 1 = strongly disagree and 4 = strongly agree); nine items on job satisfaction dimensions; and four open-ended questions about work environment and difficulties in role transition” (Casey et al., 2004, p. 304). Demographic data questions provided within the tool were not used for this study, but unique demographic data specific to this project were collected. The 25 Likert-type questions addressed comfort and confidence, and nine items directed toward job satisfaction were the section used for this project. The tool had a Cronbach's coefficient alpha level of .89 after repeated measures. Demographic information was noted from the sample group that was used. Permission to use this tool was obtained from the developers of the tool prior to using the instrument for this project. The questions were used consistently with the CFGNES tool. No grading/scoring instructions for the tool were available from the developers.
In addressing our first research question regarding what stressors were identified, participants were asked to identify all areas where stressors were encountered from a list of four items (Table 1). They could also list other stressors that were not identified on the provided list. Research questions 1 and 2 looked at the stressors identified by the participants.
The second research question assessed whether the results mirrored the original study. In the revised study, Fink et al. (2008) found that 24% of participants were stressed initially when tested, with the top three stressors listed as the NCLEX®, moving away from home, and adjusting to their new role. In the original study from 2001, 47% of new graduates reported stress and 25% stated it was due to finances (Casey et al., 2004). For our study, the top three stressors found were the NCLEX, finances, and job performance. Unlike the revised study where 24% of participants reported stress, 56% of the new graduate nurses in this study self-reported experiencing stress.
When considering question 3 from this study—the impact of anxiety levels related to the incorporation of simulation into the learning process—the research team experienced some challenges. One of the initial challenges confronted as the data were being analyzed was the lack of directions on how to interpret the results obtained from the CFGNES. Instructions for the interpretation of the tools were requested from the developers of the tool but none were provided. As a result of this challenge, the questions included in the comfort and confidence sections were reviewed to determine a means of evaluating the anxiety levels of the participants. The two researchers individually reviewed each of the questions to determine which questions were worded to reflect anxiety. A collective determination as to which questions best address stress and anxiety was determined for this study. To answer the impact that simulation has on the anxiety levels of these individuals participating in simulation experiences during the intern period, the CFGNES questions 3, 4, 7, 8, 9, 13, 14, 16, 17, and 24 were totaled to provide a calculated level of anxiety encountered by the individual at the designated time periods. Questions 8, 9, 13, 14, 16, 17, and 24 were coded both as provided and as reverse scoring given that the wording in the questions appeared to demonstrate anxiety levels of the individuals. Each question was analyzed upon its own merits, along with summarizing these 10 questions to provide a subtotal to use as the anxiety score.
Using SPSS® version 25, Tukey's honestly significance difference (HSD) analysis was used to compare the scores from the three time periods beginning with the TTP program, at 3 to 4 weeks (completion of the simulation-focused learning), and at 3 months (the end of the direct supervision period). The results showed no statistically significant difference at a Tukey's alpha p = .254 when comparing the three time periods. When considering the questions regarding anxiety (questions 3, 4, 7, 8, 9, 13, 14, 16, 17, and 24), a statistically significant level was noted between the results obtained from after the simulation-focused learning period compared with the end of the supervision period (Tukey HSD, p = .013). A difference within the stress levels was evidence between after focused learning and Independence Day. Using the ANOVA, a statistical significance was identified between the groups when the anxiety questions were coded to reflect the anxiety designation by oneway ANOVA (F [2,124] = 44.914, p = .016).
By looking at specific anxiety-related questions, several of the questions reflect a percentage of respondents who were not in agreement that the work setting was positive (Table 2). Two primary questions related to their perception of their ability to manage patient care were noted to reflect anxiety with the workloads to be addressed. Another overarching area appeared to be in their perception of their preparedness to complete the work responsibilities assigned by the agency, along with their concerns about harming patients due to lack of knowledge and experience.
Key Questions from the Casey-Fink Graduate Nurse Experience Survey
Implications for Professional Development
In this study, areas related to patient assignments, job responsibilities, and lack of knowledge and experience are key areas that need to be addressed during nurse residency programs. Because novice nurses are identifying these areas as key stress-ors, attention to them during nurse residency programs and ongoing orientation can help to alleviate some of the stressors encountered. When the stressors become overwhelming, the individuals begin to encounter burnout symptoms, which may lead them to leave the employment position and/or the profession of nursing.
This study reaffirmed the stress that new graduates face in preparing to take the NCLEX. Although nurse residency programs hire graduate nurses, the self-reported stress in successfully completing the NCLEX may inhibit the new graduate nurses from fully immersing themselves in the program. Therefore, TTP programs may benefit from providing resources and study materials to assist residents in adequately preparing for the NCLEX. Care must be given to techniques and approaches that can support the graduate nurses as they prepare to take the NCLEX examination. After this process is successfully accomplished, attention to the other stressors encountered within the transition to the work environment can be thoughtfully considered. Due to the shortened time line for assessing the participants, the stressors reflected the challenges encountered by graduate nurse interns along with external hire graduate nurses. Allowing for a long period of time between assessments with the CFGNES provides the individuals additional time to acclimate to their settings.
This study highlighted the fact that the graduate nurses face stress not only from transition from the nursing student role to the practicing nurse role, but personal stress related to finances. Addressing the financial stress that new graduate nurses face may aid in retention. Realizing that many stressors are encountered by the graduate nurses is critical for ensuring they transition successfully to a competent work status.
Limitations and Future Directions
Limitations for this study included a shorter time frame than the original study—3 months versus 12 months. Another limitation was the concern that the sample was drawn from only one acute care agency's residency program. In addition, this tool did not seem to provide the depth of information that was expected. Future studies may include the development or clarification of a tool that examines new graduate nurses' stress, both personal and professional, and the stress related to transitioning in life roles and responsibilities. The scoring for the CFGNES tool is critical. Consistency in how this tool is used within the work setting requires further clarification as to the meanings of the results obtained from the tool. Does this tool have subsections that are supported by the questions included within the tool? How can the results from the Likert scale questions be used to provide firm foundations during the development and implementation of intern and residents programs? Another challenge encountered when using this tool was the lack of a scoring guide to use when making changes and modifications to assist the residents as they progressed through the program (Table 3).
Linking Evidence to Action
The goal of this study was to examine the stressors of new graduate nurses as they compare with the original results. Although simulation is not addressed in the CFGNES, simulation has been found to affect anxiety in new graduate nurses. The CFGNES tool did aid in the identification of specific stressors and mirrored some of the same stressors, such as the NCLEX. By identifying key stressors, TTP programs can design content that aids in decreasing stress related to organizational identified stress-ors. The individuals within this study did not demonstration statistically significant changes over the course of this program, which may be due to the limitations listed above. Therefore, the lack of ability to specifically identify and assess for anxiety makes it difficult to use the tool to assess TTP outcome goals if the program's objectives were to decrease anxiety.
- Blegen, M. A., Spector, N., Lynn, M. R., Barnsteiner, J. & Ulrich, B. T. (2017). Newly licensed RN retention: Hospital and nurse characteristics. The Journal of Nursing Administration, 47(10), 508–514 doi:10.1097/NNA.0000000000000523 [CrossRef] PMID:28957869
- Casey, K., Fink, R., Krugman, M. & Propst, J. (2004). The graduate nurse experience. The Journal of Nursing Administration, 34(6), 303–311 doi:10.1097/00005110-200406000-00010 [CrossRef] PMID:15190226
- Clipper, B. & Cherry, B. (2015). From transition shock to competent practice: Developing preceptors to support new nurse transition. The Journal of Continuing Education in Nursing, 46(10), 448–454 doi:10.3928/00220124-20150918-02 [CrossRef] PMID:26430864
- Duchscher, J. (2009). Transition shock: The initial stage of role adaptation for newly graduated registered nurses. Journal of Advanced Nursing. Advance online publication. doi:10.1111/j.1365-2648.2008.04898.x [CrossRef] PMID:19183235
- Edwards, D., Hawker, C., Carrier, K. & Rees, C. (2015). A systematic review of the effectiveness of strategies and interventions to improve the transition from student to newly qualified nurse. International Journal of Nursing Studies, 52(7), 1254–1268 doi:10.1016/j.ijnurstu.2015.03.007 [CrossRef]
- Fink, R., Krugman, M., Casey, K. & Goode, C. (2008). The graduate nurse experience: Qualitative residency program outcomes. The Journal of Nursing Administration, 38(7–8), 341–348 doi:10.1097/01.NNA.0000323943.82016.48 [CrossRef] PMID:18690125
- Goode, C. J., Glassman, K. S., Ponte, P. R., Krugman, M. & Peterman, T. (2018). Requiring a nurse residency for newly licensed registered nurses. Nursing Outlook, 66(3), 329–332 doi:10.1016/j.outlook.2018.04.004 [CrossRef] PMID:29724451
- Hofler, L. & Thomas, K. (2016). Transition of new graduate nurses to the workforce: Challenges and solutions in the changing health care environment. North Carolina Medical Journal, 77(2), 133–136 doi:10.18043/ncm.77.2.133 [CrossRef] PMID:26961840
- Letourneau, R. M. & Fater, K. H. (2015). Nurse residency programs: An integrative review of the literature. Nursing Education Perspectives, 36(2), 96–101 doi:10.5480/13-1229 [CrossRef] PMID:29194133
- National Council of State Board of Nursing. (2008). Regulatory model for transition to practice report.
- Parker, V., Giles, M., Lantry, G. & McMillan, M. (2014). New graduate nurses' experiences in their first year of practice. Nurse Education Today, 34(1), 150–156 Advance online publication. doi:10.1016/j.nedt.2012.07.003 [CrossRef] PMID:22857819
- Phillips, C., Kenny, A., Esterman, A. & Smith, C. (2014). A secondary data analysis examining the needs of graduate nurses in their transition to a new role. Nurse Education in Practice, 14(2), 106–111 doi:10.1016/j.nepr.2013.07.007 [CrossRef] PMID:23932667
- Silvestre, J., Ulrich, B., Johnson, T., Spector, N. & Blegen, M. (2017). A multisite study on new graduate registered nurse transition to practice program: Return on investment. Nursing Economic$, 35(3), 110–118.
- Spence Laschinger, H. K., Borgogni, L., Consiglio, C. & Read, E. (2015). The effects of authentic leadership, six areas of worklife, and occupational coping self-efficacy on new graduate nurses' burnout and mental health: A cross-sectional study. International Journal of Nursing Studies, 52, 1080–1089 Advance online publication. doi:10.1016/j.ijnurstu.2015.03.002 [CrossRef] PMID:25801311
- Spence Laschinger, H. K. & Fida, R. (2014). New nurses burnout and workplace wellbeing: The influence of authentic leadership and psychological capital. Burnout Research, 1(1), 19–28 doi:10.1016/j.burn.2014.03.002 [CrossRef]
- Walker, A., Costa, B., Foster, A. & de Bruin, R. (2016). Transition and integration experiences of Australian graduate nurses: A qualitative systemic review. Collegian, 24(2017), 505–512 doi:10.1016/j.colegn.2016.10.004 [CrossRef]
|Job performance expectations||12|
Key Questions from the Casey-Fink Graduate Nurse Experience Survey
|Question||Disagree/Strongly Disagree (%)||Agree/Strongly Agree (%)|
|8. I feel overwhelmed by my patient care responsibilities and workload.||65||35|
|10. I have opportunities to practice skills and procedures more than once.||6||94|
|11. I feel comfortable communicating with patients and their families.||7||93|
|12. I am able to complete my patient care assignment on time.||23||77|
|13. I feel the expectations of me in this job are realistic.||5||95|
|14. I feel prepared to complete my job responsibilities.||20||80|
|15. I feel comfortable making suggestions for changes to the nursing plan of care.||30||70|
|16. I am having difficulty organizing patient care needs.||80||20|
|17. I feel I may harm a patient due to my lack of knowledge and experience.||82||18|
Linking Evidence to Action
|Strategies for Addressing Stressors in Interns|
Practice sites need to involve frontline staff in activities to develop evidence-based practice knowledge and skills.
Facilities need to utilize avenues that allow frontline staff to engage in professional development activities along with evidence-based practice projects.
The attitude toward evidence-based practice by the administration and at the bedside needs to be thoughtfully considered and encouraged.