Nursing education is a demanding experience for students. During their first year, nursing students are engaged in challenging coursework, confronted with competing demands, and may experience their first clinical placement. Spadoni et al. (2015) identified that for many students, entrance into an undergraduate nursing program is a significant transition period in their lives fraught with uncertainty, ambiguity, and confusion. Although it has been acknowledged that nursing students experience high levels of stress in academia and clinical practice (Labrague et al., 2018), few studies have examined the transitional experience of first-year nursing students (Andrew et al., 2009; McDonald et al., 2018; Payne, 2016). Examining the transitional experiences of nursing students during their first year can assist nurse educators and clinical instructors in identifying transitional points that influence students' decision to stay or withdraw from nursing programs (Jack et al., 2018; Killam & Heerschap, 2013; Leducq et al., 2012; Molesworth, 2017).
The transition from the classroom to the clinical setting is a complex process for nursing students that necessitates preparation and support (Andrew et al., 2009; Labrague et al., 2018; Leducq et al., 2012; Payne, 2016). Leducq et al. (2012) identified activities that support nursing students, such as clarifying expectations and ensuring that peer support programs are available before and during their first clinical placement. Nursing students also may benefit from training or educational sessions focused on stress and time management, as well as developing and enhancing coping skills (Labrague et al., 2018; McDonald et al., 2018).
Clinical placements play an essential role in nursing education as students are able to apply theoretical knowledge while providing care to clients and their families in the clinical setting (Gillespie, 2017; Jack et al., 2018; Labrague et al., 2018; Payne, 2016). Clinical placements provide students with an opportunity to form a new professional identity (Arreciado Marañón & Isla Pera, 2015; Jack et al., 2018; Trede, 2012), as well as the opportunity to learn and practice safe, evidence-based care to clients (Levett-Jones & Bourgeois, 2015; Levett-Jones et al., 2015; Payne, 2016).
Although clinical placements play an essential role in nursing education, the literature identifies a number of perceived stressors that students may encounter. The initial clinical placement in nursing is associated with high levels of stress and anxiety, as well as feelings of being overwhelmed and inadequate (Jack et al., 2018; Labrague et al., 2018; McDonald et al., 2018; Payne, 2016; Sun & Sun, 2011). Confronting client suffering and death are recognized sources of negative experiences (Parry, 2011; Terry & Carroll, 2008), as well as the fear of making errors that could potentially harm the client (Killam & Heerschap, 2013; Payne, 2016). Nursing students also reported feeling unwelcomed, unwanted (Jack et al., 2018; Levett-Jones et al., 2015), and undervalued by staff members during their clinical placements, which can lead to a lack of confidence (Chesser-Smyth & Long, 2013). By acknowledging potential stressors, faculty can help students anticipate stress and anxiety that they may experience when transitioning from the classroom to clinical practice.
Based on the complex nature of transitions during the first year of nursing school, supporting students at critical points of transitions could facilitate their adjustment throughout their first year. Prior to designing support strategies, it is necessary to obtain a clear understanding of the issues and concerns faced by first-year nursing students. Otherwise, interventions may be poorly conceived and inadequate to meet students' needs (Levett-Jones et al., 2015). It is imperative to listen to students and ask them about their experiences and their needs as they navigate through the nursing program and clinical practice (Leducq et al., 2012). This will allow for the design of interventions that best meet students' specific transitional needs. This study examined nursing students' transitional experiences during their first year in an undergraduate nursing degree program to identify interventions that best foster students' academic and clinical practice success.
First-year nursing students' transitional experiences are complex in nature. Meleis' Transition Theory was used to explain and understand the students' transitional experience during their first year (Meleis et al., 2000). Transitions are periods of change and instability between relatively stable periods, and are influenced by a number of variables that have the ability to change an individual (Meleis et al., 2000). Meleis' Transition Model focuses on the characteristics of transitions, such as type of transition and how they occur, which can accumulate and alter the nature of the transition. The model addresses how facilitators and barriers influence the unfolding transition (Meleis et al., 2000). Understanding the transitional experiences and what facilitated or inhibited the students' experience in their decision making, academic goals, and clinical placements can help educators successfully guide students through their first year. By identifying transitional experiences, educators are able to anticipate periods of instability that students may encounter and create strategies that can foster healthy student outcomes.
This study was approved by the institution's research ethics board. A qualitative thematic analysis design was used to examine nursing students' transitional experiences to determine support requirements needed during their first year of nursing school. A convenience sample of 156 first-year students enrolled in a direct-entry undergraduate bachelor of science nursing degree program were invited to participate in focus groups, and 42 students were recruited. Participants' first year consists of seven courses in their first semester and six courses in their second semester, including a 5-week clinical rotation. Six focus groups were held; each session was approximately 60 minutes in duration. A focus group method was used to obtain multiple perspectives on students' first-year transitional experience (Liamputtong, 2011).
The focus groups were conducted at the end of the students' first year in the nursing program during the last week of classes. The focus group moderator was a research team member who was not directly involved with the students' course teaching or evaluations. A research assistant supported the moderator during the focus groups by recording field notes of the discussion. The moderator followed a semistructured, open-ended interview guide of 14 questions. Sample questions included “Tell us about your first year experience in the program,” and “Tell us about your clinical experience.” Informed written and verbal consent was obtained from students prior to the start of each focus group session.
Focus group data were analyzed using a thematic approach as described by Braun and Clarke (2006). This thematic analysis approach was used for its flexibility to identify and analyze themes from the data (Braun & Clarke, 2006; Maguire & Delahunt, 2017). The focus group interviews were audio recorded and transcribed verbatim by the research assistants, and validated by members of the research team. Transcribed data were read individually by each author to become immersed in the data, to identify meaning of content, and to highlight recurring concepts. Data then were re-read as a team. Perspectives were analyzed, coded, and collated into potential themes, which were defined, reviewed, and named. The theme discussions added rigor and consensus to theme development. The in-depth collaboration and discussion during analysis of the data and identification of the themes among the five researchers decreased the potential for idiosyncratic biases and interpretation of data (Woo, 2019). This investigator triangulation of the focus group data increased trustworthiness of the qualitative findings (Woo, 2019). Through active discussion, the authors deepened their understanding of the nursing students' transitional experiences.
Each focus group consisted of four to 11 participants. Data saturation was achieved as data became repetitive (Woo, 2019). The focus group analysis identified four main themes: learning through others, confronting postsecondary demands, importance of relationships, and transition of self. Participants identified factors that facilitated or inhibited their transitional experience, and they described how they responded to their new situations. In addition, participants identified strategies they planned to incorporate in their second year of study and offered recommendations for future first-year nursing students.
Learning Through Others
Participants identified learning through others, which included their peers, faculty, staff in the nursing school laboratory, and staff in the clinical setting. In each of the focus groups, students described how they were able to obtain information from peers, upper-year students, or the Canadian Nursing Students' Association, which maintains an active presence on the campus. One participant described a common sentiment, “They [second-year students] provided me with information in terms of how to do better in the course [and] how to succeed.”
Participants also described faculty as a source of knowledge. One participant stated, “If we had any questions or concerns, they [the faculty] were always willing to take their own time out and meet up with us to go over something.” In each of the focus groups, participants described how they benefited from “open labs.” Open labs were scheduled times that students could go to the lab to practice their assessment skills under the guidance of faculty who were available to answer questions and review skills with the students. One participant described the benefits of the open labs, “I found [with] the open labs, I get more one-on-one time with the teacher and I learned more…. I could ask the teacher for help. I really enjoyed [the open labs].”
Simulation labs with faculty and their peers provided students with the opportunity to assess and intervene with simulated patients and situations. Students described these experiences as being helpful in preparing them for their first clinical experience. One participant stated, “Simulation helped us throw all our skills together…. We got feedback from our peers…. Now I know what to work on and what I'm confident in and what I'm not, and that really helped with clinical.”
Confronting Postsecondary Demands
This theme highlighted the various challenges students encountered in their academic studies, for example, time management and their transition from high school to university, as well as challenges they confronted during clinical practice, which included communication with clients and fear of causing clients unintentional harm.
The majority of the students expressed that their transition from high school to the first year at the university was challenging. One participant stated, “The first year of university was a big transition from high school. It was not what I expected.” Some of the challenges that students were confronted with included balancing course requirements, managing an increased workload (e.g., reading, studying demands, and coursework), and adapting to postsecondary life. Study strategies that students used successfully during high school were found to be ineffective for their nursing courses. One participant commented, “What I did in high school didn't work in university. You need to know your stuff and understand it, not just memorize and forget it after the test.”
Students found managing their time was challenging. One participant stated, “I found it really difficult balancing the seven courses in first year.” Another student supported this comment stating, “The big thing was really just trying to figure out how to manage all the work that we were given…to make time to study and also to take a break…that was hard to do.” Multiple course demands did not allow students time to care for themselves; as one participant said, “I didn't take care of my mental health. I focused more on studying and making sure everything was organized for school first.”
During the second semester, students were enrolled in six courses and simultaneously attended clinical practice 1 day a week for 5 weeks. Students reported feeling nervous about attending clinical and talking to clients. One participant said, “I think the biggest fear for me was just having that fluid conversation and communication with the patient.” Students also feared upsetting their clients and causing the clients unintentional harm during care. One participant commented, “I was afraid… what happens if the patient falls while I am there.”
Importance of Relationships
This theme emphasized the significance of support systems required to facilitate students' transition throughout the first year. Participants discussed that they received support from their families, peers, and educators (i.e., faculty, clinical instructors, and clinical placement staff). Each source of support was used throughout the year at various times depending on the students' needs.
Participants reported that their family were an important source of support and that family members assisted with practicing their skills and confidence level. One participant noted that “practicing on my family members when I'm home” was how family members supported this participant's skill development. Another participant commented:
It makes me feel confident that I'm making my parents happy [by being in nursing school]. It's something that I want to do. It's something I'm happy about. I'm proud of myself [and] they're proud of me so it's just the added confidence.
Another important relationship for students throughout their transitional process was their relationship with their peers. One participant stressed that it was important to “use your peers around you to help you get through it” when discussing their first-year experience. Another participant supported this statement by saying it “helped a lot having a really good group of friends…to split up [study] objectives…and alleviate some of the nerves.” Participants from each focus group agreed that “building relationships with your peers” is an important tip for future first-year students. One participant explained, “You need to build relationships, you need to have somebody to practice on, somebody to talk to you when you're stressed, it's really helpful.” Participants expressed that peers were “going to be the ones that are going to help you. Nursing is not something that you do on your own, you have to collaborate with people.”
Relationships with faculty, clinical instructors, and clinical staff also were described as assisting the students' transition. Participants shared that the guidance and feedback they received from their educators helped to support their learning and clinical experience. One participant commented that “having feedback actually really helped…my learning.” Another participant talked about their clinical placement saying it was an “amazing experience because my clinical instructor was really open and she was willing to help us regardless of whatever we do.”
Transition of Self
This theme included participants' perceptions of self and a deeper understanding of how they had grown and changed over time. Participants commented about developing strategies for success and how having a greater sense of self-awareness had contributed to their transition of self, which was noted especially after a stressful or challenging experience. One participant identified that after receiving a poor evaluation, “self-reflection actually really helped…[with] noticing my weaknesses and how to actually make it better in the future.” Another participant commented that using reflection after a challenging day at clinical helped her understand that she had not prepared well and afterward she “made an extra effort to research my patient's diagnosis, their medications, [and] best practice methods.”
Participants also discovered how they changed over their first year and became aware of their new identity as a nursing student. One participant noted that, “Empathy, advocating for your client, that has not only helped me in the clinical setting but just like as a person…. I kind of changed as a person…. You actually do think about other people more.” Another participant described their new identity associated with wearing the nursing uniform as, “It feels a little more empowering when you put that uniform on, you know you're a nursing student, and you know you have a purpose.”
The purpose of this study was to examine nursing students' transitional experiences during their first year in an undergraduate nursing degree program and to identify interventions that best foster students' academic and clinical practice success. The findings identified four themes that highlighted students' transitional experiences and the perceived supports they require to assist them in this transition. The importance of these findings revealed the need for faculty-supported initiatives as nursing students navigate throughout their nursing program.
Transitional experiences encountered by students need to be identified to support students throughout their first year in a nursing program. Each nursing program varies regarding course workload and first clinical experience. Faculty must reflect on their specific program to identify key transitional moments that students may encounter and recognize how these key moments may impact student success. According to Meleis et al. (2000), being aware of support systems and engaging with others can assist in a positive transition. Participants identified multiple sources of knowledge that they learned from others and described how they incorporated these supports when confronting postsecondary demands. Faculty were identified as a key source of knowledge and had the capability to guide students through the nursing program during key moments. One recommendation is to create workshops for faculty that focus on how they can increase their connection with students, including communicating about critical moments students may encounter and how to encourage students to develop healthy support systems (Payne, 2016).
Development of students' knowledge, skills, and abilities are required to meet the demands of the nursing program. McDonald et al. (2018) found students who were not able to transition and build resilience may struggle with stressors related to multiple demands and may not be successful in their studies. Students also will experience highs and lows during their transition; however, each challenge they confront and overcome can encourage them to evolve as they begin to form their nursing identity.
In the focus group discussions, participants described the need to reevaluate their previous learning methods from high school to meet the demands of the university. Meleis et al. (2000) suggest that when individuals are able to manage their new environment and master the skills required, a healthy transition occurs. Students' ability to advance their learning techniques to meet postsecondary demands demonstrates their capability to master their new environment and demands of the nursing program. Students' awareness, perception, and recognition of their transitions can influence their transition in a positive manner (Meleis et al., 2000). One recommendation is to create an orientation that highlights and differentiates postsecondary demands and nursing program expectations to assist students in developing effective learning strategies (Hamshire et al., 2013; Leducq et al., 2012; O'Donnell, 2011).
The findings of this study are consistent with other studies that have reported levels of stress and anxiety experienced by nursing students during their first clinical placement (Jack et al., 2018; Labrague et al., 2018; McDonald et al., 2018; Payne, 2016; Spadoni et al., 2015; Sun & Sun, 2011). Attending clinical placement was identified as a critical point and can be a turning point in a student's transition. Meleis et al. (2000) characterized critical turning points by increased vulnerability and awareness of change, which can be a key moment for faculty to support a student's transitions.
It is important for nurse educators to help students integrate their knowledge into practice, reinforce their role as a nursing student, and nurture the development of their new professional identity (Davies, 2005; Meleis et al., 2000; Ramsay et al., 2014). In addition, recommending that nursing programs collaborate with clinical partners is essential to support students' transition during their clinical placement experience. Developing programs that focus on optimizing students' learning experiences (Labrague et al., 2018) and increasing students' engagement in clinical practice is vital. Creating student-specific orientations to the unit and demonstrating professional role modeling can foster students' transition into their first clinical placement.
Student relationships with peers, faculty, and clinical instructors are important elements in their transitional journey. During their second semester, students enter clinical practice and create new relationships with a clinical instructor and a group of peers that they may or may not know. This experience can be challenging due to the new environment and clinical team (Hamshire et al., 2013). One recommendation is to create an open forum for collaboration and peer discussion. Using an open social media platform (e.g., Facebook® or Twitter™) as an adjunct to clinical visits by faculty could help students' transition into clinical practice and reinforce students' knowledge.
Incorporating social media can be an interactive strategy for all students to connect, discuss new information, and support each other through online engagement, which has the ability to increase self-confidence and peer collaboration (Duke et al., 2017; Price et al., 2018; Watson et al., 2016). Adding interactive videos, case studies, and reflective questions to a faculty-guided social media site (i.e., Facebook group page or Twitter feed) can support students during clinical practice. It is important to note that when using social media as a teaching strategy, nurse educators should include an orientation that discusses privacy, e-professionalism, and best practice guidelines to educate students about using social media appropriately as a professional (Duke et al., 2017; Price et al., 2018). Implementation of this recommendation would create multiple opportunities for peer networking and support as a way to facilitate a successful transition to the clinical area.
During their first year, students described developing a new professional identity through self-awareness and reflective practice. Students identified changes within themselves that included increased confidence, enhanced coping skills, and a deeper connection with others. According to Meleis et al. (2000), these changes are reflective of a healthy transition. By incorporating intentional teaching strategies, students' professional nursing identity can be nurtured through attainment of knowledge, self-awareness, and reflection, as well as through the development of critical thinking (Arreciado Marañón & Isla Pera, 2015; Day et al., 2017).
The development of a healthy professional identity is a significant outcome of nursing education (Neishabouri et al., 2017), in which nursing programs play an important role. A recommendation for developing students' professional identities could include emphasizing the need for the development of professional identities early in the curriculum to enhance students' transition during their first year (Browne et al., 2018). Educators can support the growth of students' professional identities by encouraging students to make connections with professional nursing organizations and by encouraging reflective practice to facilitate students' professional growth throughout their studies.
This study used a convenience sample from one undergraduate nursing degree program, which may limit transferability of the findings. Repeating the study in different nursing school settings to compare first-year nursing students' experiences would be beneficial. Findings related to first-year nursing students' experiences may not reflect other disciplines due to different course expectations and experiences. Further research is needed to determine whether implementation of recommendations has an impact on nursing students' transitional process in their first year of study.
It is important for educators to understand students' transitional experiences to implement effective strategies. Study findings highlighted the transitional challenges and the perceived supports required by students to assist them throughout their first year. Students identified peers, faculty, clinical instructors, and staff as supports during their transition in their first year. Faculty support and involvement was identified as an important factor to student success, which emphasizes the need for faculty involvement in program planning.
The study findings demonstrated students' knowledge sources, relationships, and competing demands impacted their transition throughout their first year and the development of their professional self. These findings can help guide faculty in enhancing their teaching strategies to support nursing students' success. Designing student-specific orientation, teaching and learning strategies, and support systems can benefit nursing students' transition and success during their first year.
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