A graduate nurse, reflecting back on her transition process during orientation, provided a simple but jwerful statement representative of her experience and echoed by the study cohort:
I thought, I'm the RN now, so I have to know the answers. I can't say I'm a student anymore. I worry about not knowing enough, not knowing what to do. Should I do this, or should I do that? Did I miss anything? I feel like I'm walking a fine line.
Transitions are complex and multidimensional. They are a result of and result in changes in life, health, relationships, and environments (Meléis, Sawyer, Im, Messias, & Schumacher, 2000). Transitions can be further defined as starting with an ending, followed by a period of confusion and distress, and leading to a new beginning (Williams, 1999). Within the nursing profession, the transition from student to nurse is a common rite of passage experienced by all graduate nurses. The orientation period marks the beginning of a journey and is perhaps the most crucial part of the transition. It influences both immediate and long-term outcomes in the process of becoming an expert nurse.
It is well documented that the first 3 months of employment as graduate nurses represents the most stressful time in nurses' careers (Godinez, Schweiger, Gruver, & Ryan, 1999). In addition, approximately 35% to 60% of new graduates change places of employment during the first year, negatively affecting both the nurses and the health care institutions. Furthermore, the nursing profession itself is going through a transition (Williams, 1999) and is in need of new and innovative orientation models. To address these challenges, it is imperative that graduate nurses are provided with a transition framework that facilitates their growth and the achievement of their potential. This study explored and described graduate nurses' transition experiences as they walk the fine line between student and nurse. Phenomenological analysis of the participants' responses provided a rich description of this transition and highlighted the major themes of the process.
An extensive literature review revealed a body of knowledge regarding the transition from student to nurse. The author searched CINAHL, PubMed, Eric, and Academic Elite databases using the keywords "transitions," "orientation," "preceptors," and "graduate nurse." The search revealed many articles were written on this topic during the late 1970s and 1980s, most of which were quantitative. The literature within the past 10 years, although fewer in number, demonstrates the importance of developing new and innovative orientation models. During the past 10 years, no phenomenological studies were published concerning graduate nurse transitions.
Brasler (1993) examined the effectiveness of different components of the orientation program on the clinical performance of 75 novice nurses. Multiple regression analyses using Schwirian's Six-Dimension Scale of Nursing Performance found that the best predictors of performance were support provided by colleagues and preceptor skill levels. A positive correlation was found between preceptor expertise and novice nurses' clinical performance (r - -,63;p < .001). The study's findings indicated the importance of a holistic orientation program that addresses both knowledge and skill needs in preceptors, as well as psychological support of novice nurses.
Oermann and Moffitt-Wolff (1997) examined 35 new graduate nurses' perceptions of clinical practice. The study findings revealed that new graduates experienced a moderate amount of stress during orientation, especially in the areas of experience, interactions with physicians, organizational skills, and new situations. No correlation between stress and social support was found in this study. Significant correlations were found between social support and stimulation in clinical practice (r = .57; p < .001) and self-confidence (r = .39; p < .029). The findings suggest the need to address these Stressors during the orientation process.
During the past few years, a few investigators have explored the transition from student to nurse from a qualitative perspective. Godinez et al. (1999) examined the transition from graduate to staff nurse during the first 3 weeks of orientation. Content analysis of daily feedback sheets completed by 27 graduates and their preceptors revealed five themes: the need for support, guidance, and experience, and recognition of institutional idiosyncrasies and interpersonal dynamics. The study revealed the conflicts new graduates experienced related to the changing pressures and priorities from the academic to service setting.
Holland (1999) used an ethnographic methodology to explore nursing students in transition, which she referred to as "a journey to becoming" (p. 229). Observations and interview responses to open-ended questions were analyzed. Holland (1999) depicted the transition as a stressful, yet growth-producing, experience and emphasized the need to gain skills; give care, learn, and do; and differentiate the role of student versus nurse.
The current literature concerning the transition of graduate nurses is limited but does address the importance of comprehensive orientation programs, preceptors' competency levels, and graduates' satisfaction (Brasier, 1993; Godinez et al., 1999; Holland, 1999; Oermann & Moffitt-Wolff, 1997; Treadwell, 1996). Additional literature exists that emphasizes the importance of comprehensive orientation programs for new nurses (Balcain, Lendrum, Bowler, Doucette, & Maskell, 1997; Beeman, Jernigan, & Hensley, 1999). Further research is needed to describe the lived experience of graduate nurses using a phenomenological approach.
A phenomenological method was used to examine and describe graduate nurses' orientation experiences. Phenomenology is a qualitative method that examines and describes the lived experience from the individuals' perspectives. Integral to the phenomenological philosophy and methodology developed by Husserl (1962) is an a priori knowledge of the phenomenon. This is referred to as bracketing and brings to the investigator's consciousness his or her own presuppositions and biases, which could affect the research process and description of the phenomenon. Merleau-Ponty (1956) added that to see the world it is first necessary to disrupt one's familiarity with it. This temporary disruption allows the essence of the phenomenon "as lived" to be discovered. In this study, the researcher reflected, self-questioned, and journaled to bring personal perceptions, presuppositions, and biases to the surface of consciousness. The following presuppositions surfaced:
* Transitions in general are stressful.
* Students are anxious regarding the transition from student to nurse.
* Nursing staff is often reluctant to assume a preceptor/mentoring role.
* Students are not always adequately prepared in school to assume the role of staff nurse.
* Orientations developed within a caring framework can make an important difference in graduate nurses' transition.
The researcher continued reflecting and journaling throughout the project because each step brought forth new presuppositions that required acknowledgment.
In this study, the lived experience of tranaitioning from student to nurse during orientation within a caring framework was examined from the perspective of graduate nurses. Data were analyzed using Colaizzi's (1978) phenomenological method.
Selected Examples of Significant Statements With Corresponding Formulated Meanings
Two Examples of Theme Clusters With Their Corresponding Significant Statements
Approval of the study was obtained from the hospital's and university's Institutional Review Boards. To be included in this study, graduates had to have participated in the hospital's caring-based orientation, had be able to articulate their experiences, and did not directly work with the investigator during orientation. Ten graduate nurses, of a possible 18, were approached to participate. The study's purpose and procedure were fully explained both verbally and through a written informed consent letter. All nurses agreed to participate and signed the consent letter. Interviews were conducted in a quiet, private room in the hospital to increase participants' comfort level and to facilitate free expression. The interviews lasted from 30 to euro0 minutes and were audiotaped.
Demographic data were also collected at this time. A professional transcriptionist transcribed the interviews verbatim.
The sample consisted of 10 female graduate nurses, ranging in age from 22 to 40. Seven nurses were single, 2 were married, and 1 was divorced. Eight nurses held associate degrees, and 2 had baccalaureate degrees. The common denominator was the hospital's orientation program, which was based on a caring framework. The newly developed orientation model was grounded in a caring philosophy and emphasized collaboration between nurse educators in academia and hospital service, with the goal of facilitating the transition of graduate nurses.
Analysis of the participants' transcribed responses using Colaizzi's (1978) method began with an in-depth review of each sentence. From this review, 224 significant statements were extracted and transformed into formulated meanings. These meanings were then collapsed into 10 themes. Tables 1 and 2 present a partial audit trail of these steps. An exhaustive description was written to identify the essence of the phenomenon. The final step was validation of the themes and exhaustive description by 4 of the participants.
Theme 1: Mixed Emotions
All participants expressed similar sentiments regarding successfully completing school and obtaining their first nursing job. Feelings of pride and accomplishment were vividly described. One participant stated, "When I opened the envelope [from the board of nursing], I just started crying. Fm a nurse! I'm a nurse! It was one of the happiest days. I passed. I did it. I succeeded!" Another participant echoed similar thoughts, "I was relieved to finish school because there had been a lot of stress and pressure. I felt a sense of pride in finishing the program."
Despite their positive feelings, graduates also described feeling scared and nervous as they began orientation. One participant said, "It was scary because now all of a sudden you don't have that fallback of the instructor.... I can't say I'm a student anymore, so I have to know all the answers, and that was scary for me."
Theme 2: Preceptor Variability
Graduate nurses' perceptions of their preceptors significantly affected their thoughts, as well as their progression. Preceptors who were seasoned and knowledgeable brought forth positive feelings, as one graduate described, "I've had great preceptors. They were all very knowledgeable, and they are experts, that's for sure. They have been here for years, and they know what they are doing. I have learned a lot."
On the other hand, when preceptors were less experienced or inconsistent, graduates* perceptions were negative, as exemplified by this participant:
It was confusing because I would have a different preceptor every other day. I must have had six different ones. Everyone had hie or her own routine and way of doing things, and they would say things like, "Why are you charting on that?" They kind of made me feel stupid over and over again. That was a little frustrating and confusing - one is telling me this, and another is telling me that.
Another participant stated:
One day during orientation, I came onto the floor like I normally do. It was on my schedule to be on this floor with this person. So I go in there, and I take report on all my patients, and they call back and tell me you are going to the fifth floor tonight. It was four o'clock when I was told I had to switch floors and preceptors. I thought to myself, "What are they doing?" You are confusing me and screwing me up. It was very frustrating.
Theme 3: Welcome to the Real World
The graduates quickly realized the many differences between work and school in terms of ideology and pragmatics. As one graduate commented, There is a huge difference between school and work." The realization of the responsibility involved in nursing was expressed by all participants and, at times, frightened them. One participant stated, "I was scared to death when I realized how much responsibility was on me. I needed to truly realize how much rests on my shoulders every time I walk into this building."
From a practical perspective, graduates found that work presented different outcome objectives. Patient caseload and time management were the most commonly cited differences. One participant asserted, "I was trained in school for two or three people, not to keep track of six or seven. It's totally different. The hardest part was time management." The imperfections of everyday nursing became a reality as these new nurses practiced in the real world.
Theme 4: Stressed and Overwhelmed
The graduates felt anxious and insecure at first when faced with new tasks and increasing responsibility. New skills, such as starting intravenous lines [IVs] and talking with physicians were frequently cited as major Stressors. One participant said, "I called everyone the night before my IV training. I don't want to stick people, and I was flipped out by that. I hated it for the first six or eight you have to do. I hated it!"
Increased patient load and time management were the responsibilities the participants spoke about most.
Repeatedly, participants expressed concerns about their abilities. One graduate provided a rich description of a difficult evening:
One evening, I had four admissions come in, and t was up to six patients. It was like, boom, one admission came in, and then another, and I had two that just came from the recovery room. No matter what I did I couldn't keep up, and I kept trying and trying, but there were more things I had to do, more and more, and I was overwhelmed. I thought I am so disorganized, why can't I keep up, will I ever get this?
Theme 5: Learning the System and Culture Shock
Many times, participants expressed frustration related to trying to learn and understand the institutional system. One graduate described her frustration with navigating the physician on-call system:
It is very difficult at this hospital to call a doctor. Patients may have medical residents, and there are surgical residents, and then if you have a GU [genitourinary] patient you call another resident. Are they private or team patients, and who is covering for them? It's very difficult to know who to call. It's overwhelming. Sometimes I just keep screwing up and calling the wrong person. Will ever get this? It's so frustrating and confusing.
Fitting in was important to graduates, and socialization to the unit culture presented yet another challenge. One participant described feeling connected to the unit as a process, "It took a while to feel like you want; I think that's anywhere you go." Graduates' perceptions of the staffs reception to them greatly affected their feelings about the experience. One participant expressed the anguish of feeling rejected and how she attempted to resolve it:
When I came to evenings, my first experience was with one of the best nurses I have ever had the opportunity to work with; however, she informed me that she didn't feel I belonged in a float position as a new nurse, and she felt it was downright dangerous and was going to the staffing office to speak about it. I was mortified.... Finally I approached her and asked if I had understood her correctly? [I said] I would really like to talk to you about it this because I'm not a confrontational person, but I can't let this kind of thing build up. After that, we talked, things were much better. I was just her target that night.
When the graduates felt accepted, their description of the experience was significantly different. One participant said, "I lucked out. The staff was great they made you feel comfortable, and they were happy to help you out. I haven't butt heads with anyone yet, and I'm glad. I think I've transitioned well."
Theme 6: Not Ready for Dying and Death
All participants commented on coping with death and dying issues of their patients and families. It became clear this was an emotionally charged experience for participants. One participant tearfully recounted her experience with the death of a patient:
A big milestone that I have faced during orientation was dealing with death. One day I was working with my preceptor, and a lady coded out of the blue, and she died. That was rough. She was my patient [who] I was talking to 10 minutes ago and then she died. It was really difficult for me.
Another participant expressed her lack of readiness to handle end-of-life issues:
This was the one thing we weren't allowed to see in school. If someone coded, you were never allowed to stay in the room. Even during orientation when another nurse's patient coded I asked if I could go in because someday it will be my patient, and they wouldn't even let me do that.
Another participant's comments reflect her evolution of thought on matters of death, "I'm still not through the death thing yet, honestly, but I understand it's part of Ufe, it's a privilege to be with these people in their last moments."
Theme 7: Dancing to Their Own Rhythm
As orientation progressed, graduates began to develop organizational skills that allowed them to move forward. Their preceptors presented certain styles, but now they were dancing to their own rhythms. One participant said, "I have a set pattern that I follow every night. It took me weeks to decide what worked best for me." These organizational skills built their confidence and afforded a sense of accomplishment. One graduate described thinking, "I finally got it. I see what I have to do now."
Participants also learned that sometimes things do not go according to plan. As one participant stated, Tm a very organized person, but no matter how organized you seem, things come up and can throw off your whole night. You have to learn to go with the flow. That's where prioritizing comes in."
Theme 8: Stepping Back to See the View
Throughout orientation, graduates used self-reflection to evaluate their progress. It was important for them to step back and see how far they had come since graduation. They found comfort and strength in this process, which built their self-confidence and belief in themselves. In addition, reflection provided a framework for graduates to plan their goals. One participant said:
The past few months have been a very educational and self-reflecting experience because I was able to take a look at myself, what I can and can't do, and see things in myself that I hadn't seen before and how far I've come.
Theme 9: The Power of Nursing
All of the graduates realized the value of nursing. Although stress was unanimously expressed, it did not cloud participants' perceptions of the powerful effect their work had on both themselves and their patients. One participant summarized the personal effect by saying, "Orientation has been full of new things. A lot of learning, a little anxiety, but a lot of rewards. I feel good that I am sharper with my skills, getting my act together, working things out." Another participant described her perception of the effects of nursing care on patients:
I think a lot of jobs are physical and mental, but nursing is especially emotional. We interact with people in the most difficult times of their lives. What we say and do can make a huge difference. When I'm able to catch something before it becomes a problem or say something that helps, I know I've made an important difference for my patients. Nursing was the best choice for me; I know I'm in the right place.
Theme 10: Ready to Fly Solo
Overall, participants commented favorably on the orientation program, and most expressed feeling welcomed and supported. One participant commented:
I think they did a good job orienting us overall. I felt really welcomed. I received a lot of support and encouragement, and that's been great. It was nice to have the education consultants there, just in case you needed them.
Each participant, in her own way and time, verbalized readiness to end orientation, and for most, 12 weeks was sufficient. One participant stated, Tm a little nervous about going off orientation, but I definitely feel more secure that I can do this, so I guess I'm looking forward to being on my own, and I know that my preceptors will still be there, but now they'll be my coworkers."
Orientation was extended for a few graduates. One participant said, Tm almost there, with 2 more weeks, I will be able to get the routine down and feel more confident."
Perhaps this participant best summarized the feeling the graduates had at the end of orientation, "It was scary at first, but now it's just something I do. Fm ready for the next step."
Orientation was both an end and a beginning. Graduates arrived at their new positions with mixed emotions. Feelings of pride and happiness were tempered by anxious anticipation. The graduates' preceptors had a significant effect on both the transition experience and the outcome. Graduates who worked with preceptors who displayed professional qualities, such as seasoned experience, critical judgment, and clinical expertise, combined with a caring, supportive attitude, facilitated healthy transitions. Conversely, when preceptors did not own these characteristics, graduates' perceptions were less positive and their progress was delayed. Consistency also played a key role. Even when preceptors were not described as ideal, a certain level of comfort was achieved through consistent interactions that allowed progression.
Stress was the most powerful common experience of the graduates, stemming from the multiple tasks and roles they had to assume. Their confidence slowly increased as they developed organizational and prioritizing skills. Graduates eventually found their own style and rhythm and began feeling a connection to the unit and institution.
Throughout orientation, graduates used self-reflection to both gauge their perception of progress and guide their future goals. Realizing how far they had come allowed them to begin trusting their judgment and raised their expectations of what they could become. Despite the stress of orientation, graduates found great meaning and value in their work.
By the end of the 12 weeks, most graduates felt ready to be independent and took comfort in knowing they were welcomed and supported. A few felt they needed more time. The graduates had discovered both the joy and pain of nursing and embraced the totality of the experience. They had successfully navigated a rite of passage in the transition from student to nurse.
REFLECTIONS ON THE FINDINGS
This phenomenological study builds on previous descriptions of the transition fi-om student to nurse, validates previous quantitative and qualitative studies, and provides a unique contribution to the body of knowledge on this topic. The findings of this study validate Brasler's (1993) quantitative findings that preceptor skills significantly affect new graduates' perceptions and progress. In addition, they validate Oermann and Moffit-Wolff's (1997) results that stress and socialization significantly affect graduates' role acquisition.
The themes and significant statements revealed in this study were similar to the five themes identified by Godinez et al. (1999): real nurse work, guidance, transitional process, institutional context, and interpersonal dynamics. In addition, they were consistent with themes previously identified by Holland (1999) - being a student nurse, giving care, gaining skills, learning to become, performance, a stressful experience, and learning and experiencing.
This study also provided a unique contribution to the growing body of knowledge related to the transition from student to nurse in that it identified new themes not discussed in other studies, specifically the graduates' lack of preparedness to cope with death and dying and the key role self-reflection plays in the transition.
This study has important implications for nurse educators in academia and service, preceptors, and new graduates. Perhaps the most important implication is the need for collaboration between education and service, as identified by Godinez et al. (1999), for successful transitions. Implications for nurse educators in academia include increasing student assignments from caring for 2 or 3 patients to 4 or 6 patients to decrease the anxiety associated with real-world nursing. In addition, ways to cope with death and dying issues must be built into curricula. Detailed discussions and clinical experiences with managing information, talking with physicians, and participating in interdisciplinary conferences are also needed.
At the other end of the spectrum, nurse educators in the service sector could facilitate this transition by taking more time during orientation to explain the institutional system, limiting the number of preceptors assigned to graduate nurses, and carefully selecting preceptors. In addition, the inclusion of support groups for new graduates and suggesting the use of a journal may foster socialization and self-reflection.
Preceptors would benefit from ongoing continuing education and training programs to help them address the needs of graduates during role transition. Finally, new graduates can use the information gleaned from this study to better understand the transition process, thus decreasing their anxiety related to the most stressful time in nurses' careers.
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Selected Examples of Significant Statements With Corresponding Formulated Meanings
Two Examples of Theme Clusters With Their Corresponding Significant Statements