Towards unpredictable-The anticipations of nursing students of the transition to a registered nurse

The aim of this study was to describe anticipations of graduating nursing students of the unpredictable transition to a registered nurse. The graduation can be stressful and challenging and nursing students feel insecure about their competence and ability to start the working life. A descriptive design was used with a modulated narrative method. 16 nursing students wrote narrative essays about their anticipations of the transition. The essays were analyzed using inductive content analysis. The anticipations of the transition can be divided into three main categories: fear and stress of competence, opportunity to learn new skills and orientation to the future. The results can be utilized both in the curriculum development of nursing degree programs and in mentor training programs. The study findings support the development of transition facilitating methods to the final clinical practicum. Correspondence to: Leena Salminen, Senior Lecturer, PhD, Adjunct professor, Department of Nursing, University of Turku, Turku, Finland, Tel: +35823338576; E-mail: leena.kaarina.salminen@utu.fi


Introduction
The transition from a graduating nursing student (GNS) to a registered nurse (RN) can be challenging and stressful [1]. It is common for GNSs to feel insecure about their competence level which complicates the adaptation to new role as a RN. Demands on GNSs are high, but GNSs are noted to be poorly prepared for responsibilities and the reality of nursing [2][3][4]. The transition is an individually experienced, a nonlinear unpredictable and challenging process [4,5]. Duchscher [5] quotes Kramer [6] and defines this period as "Transition Shock": the aspects of a new graduate's roles, responsibilities, knowledge and relationship during the transition.
During the transition, GNSs desire to improve their clinical skills, increase clinical experience and get information about the practical aspects of being a RN [3,7]. The final clinical practicum aims to improve GNSs' professional skills, confidence, preparedness for nursing practice [8,9] and awareness of the responsibilities before stepping into working life [8]. Besides the developmental and intellectual adaptation, taking on a new role as a RN includes also adaptation at the socio-cultural and physical level [5].
Realities of nursing do not always match the expectations of GNSs' it might increase the feelings of insecurity [4,10,11]. If these feelings are ignored during the transition, the adaptation to working life can be complicated [2,12] and have negative impact on self-confidence, critical thinking and clinical knowledge of GNSs [2,4]. Unpreparedness and negative experiences during the transition can effect on new nurses´ willingness to stay in profession [13,14].
The aim of this study was to describe anticipations of graduating nursing students of the unpredictable transition to a registered nurse. The research question was: What kind of anticipations GNSs have about the transition from GNS to a RN?

Methods
A descriptive design with a modulated narrative method was used. GNSs (n=16) were enrolled from the nursing degree programme in one polytechnic in Southern Finland. Finnish nursing degree program consists of 210 credits (3.5 years) comprising two-thirds of theoretical and one third of clinical studies.
Inclusion criteria were: (1) students graduating at ongoing semester, (2) had not had final clinical practicum before the data collection.
The data was collected in December 2010 from 16 GNSs from two nursing degree programme group fulfilling the inclusion criteria at the time of data collection. The GNSs were asked to write an essay with answering to the following question: "What kind of anticipations you have about forthcoming role change from GNS to RN?" The essay was written anonymously. Background information was: age, gender, prior work experience in healthcare and possible previous health-related education. The GNSs returned the essay to the researcher in sealed envelopes. It took on average 30 minutes to write the essays. The total amount of collected data was 16 hand-written pages.
Inductive content analysis was used. The expressions of GNSs anticipations about the role change were the unit of analysis. The length of the expressions varied from a few words to long sentences. The number of expressions in one essay varied from between five and eight. A large number of expressions were written down in a way that did not alter their original content. Finally, a total of 90 expressions were chosen. Based on the analysis, nine subcategories were constructed and were combined into three main categories ( Table 1).
The study was carried with a good scientific practice [15]. The written consent for data collection was obtained from the polytechnic where the study was carried out (09/2010). Written essay was seen as an informed consent. The anonymity was ensured in a way that only the researcher read and processed the essays without any connections to the participants.

Findings
All participants were female between 22 and 37 years (average age 24.6). Four of the students had previous associate degree nursing education (licensed practical nurse). The previous health care work experience varied between 6 months and 4.5 years (average2.2 years). The anticipations of the transition from GNS to a RN were divided into three main categories: 1) Fear and stress of competence, 2) opportunity to learn new things and 3) orientation to the future (Table 1).

Fear and stress of competence
GNSs expressed fear and stress about their lack of knowledge, demands of the employer and increasing responsibilities. GNSs felt that they have lack of knowledge about different illnesses, physiology and medical treatment-related issues. GNSs were afraid that they would not be able to cope with their future work and not remember all that they had learnt. Several felt unprepared to act independently.
By demands of the employer, GNSs meant either the competence requirements or attitudes towards the recently graduated nurse. GNSs felt that the work community and its atmosphere are significant in terms of the transition experience. GNSs assumed that the employer would have certain expectations about hiring professionals and this caused stress. GNSs did not always feel themselves completely professional and they thought that the employer would expect them to hold the latest nursing knowledge. The GNSs felt that they were expected to be competent right after graduation; however they hoped the employer and co-workers would understand GNSs' incompleteness in nursing. The GNSs perceived the nursing profession to be a very demanding field that requires responsibilities and ability to deal with them and these caused worry. Students felt stress about mistakes and highlighted the significance of maintaining competence in all nursing interventions, especially in medical care.

Opportunity to learn new things
A willingness to learn new things appeared in GNSs' expressions about the transition experience. They felt that learning would occur in the form of learning from colleagues, learning through work and through continuing education.
GNSs showed their openness to learn new things after graduation by asking for advice from colleagues. Daring to ask even silly questions was seen as important. GNSs felt that being introduced to the new work is important and they hoped that they would get such an introduction at their future workplaces. In most cases GNSs were convinced that the real learning and adaptation to the role of nurse will take place through working in clinical practice. At the same time, they were hoping to receive a confirmation about their choice of profession and to finally feel good about what they do.
The voluntary nature of learning and continuing education was brought up repeatedly. Most of the GNSs expressed a motivation to develop themselves after graduating and willingness to participate in education of their own field of interest.

Orientation to the future
Some GNSs were puzzled about giving up the role of a student, some wrote mainly about positive expectations and some were thinking about the impacts of the role change on life.
Some GNSs felt that burying their former student identity would be challenging and described that there was a certain feeling of sadness when they had to leave the safe role of a student and their fellow students. Even if the GNSs expressed feelings of fear and stress about of the coming role change, they also expressed positive aspects of their future. In most cases, the positive expectations were happiness and enthusiasm about completing their studies, fulfilling the set goals and the beginning of their nurse career. In addition, GNSs expressed that after graduating they would be able to act in nursing in the way they perceive is the best one. GNSs were aware adapting to a new role and the burden of beginning their working life.
GNSs felt that along with the role change, they would also move into the role of an adult. They felt that by graduating into a profession they would cross a line between youth and adulthood and this caused anxiety for some of the GNSs. GNSs thought that life would become more organized and take a more responsible form. Many also felt relief at the prospect of transferring to working life because now they would have the opportunity to focus on work only and would be better-off financially.

Discussion
The findings of this study were mainly in line with previous studies [5,8,12]. The transition from GNS to RN caused fear and stress, but at the same time GNSs viewed it positively as representing the opportunity to learn. The fear and stress was mainly focused on GNSs' lack of knowledge in terms of treating illnesses and medical care [3], on how they would manage in their future work environment in general and increasing responsibilities [11]. Earlier studies have reported that GNSs understand the meaning of self-responsible practice [8] and they worry about the challenging nature of nursing work [10].
In this study GNSs were worried about the high demands of the working environment and the future employer. This is exactly what Duchscher [5] describes in her "Transition Shock Model". This study showed that the transition already begins during the final semester and before the final clinical practicum. The GNSs' feelings should be recognized and reflective discussions should be conducted with them about these feelings. Overall, there is a need for more extensive cooperation between nurse teachers, GNSs and mentors to reduce the stress and fear as well as to help to find new methods to facilitate the challenging transition from GNSs to RN during the final clinical practicum. This might also help to improve GNS's individual coping strategies, allowing them to feel that they manage nursing and stay in the profession.
GNSs' reflections about the future aspect of the transition mainly related to giving up the safe role as a student. For GNSs, the positive aspects of the impending transition included ending their studies and being enthusiastic about reaching the goals. Despite the feelings of fear and stress, students perceived the challenges that working life might bring in a positive way.
There are previous empirical researches about GNSs' role change during the transition from GNS to RN, but there is a need for studies concerning the importance of the final clinical practicum. The results of this study can be utilized in developing mentor training programs and as a base for reflective discussions and peer work both in theoretical and practical studies. There is a need for robust evidence about transition facilitation from GNS to RN. Intervention testing requires collaboration between health care organizations, educational institutions and researchers.
The data was gathered from two student groups in one polytechnic, albeit in a large one, and only 16 GNSs took part. However, the volunteer participating GNSs gave a rich data to be analyzed. The consistency of coding was ensured by a consensus discussion of two researchers during the analysis. The narrative data collection method and the small sample size must be considered when scrutinizing the extent to which the results can be generalized.

Conclusions
The anticipations of GNSs discussed in this study provide a way to understand the emotional and challenging transition from GNS to a RN. The findings provide information for nursing education and mentors to develop more methods to support the future graduates to be prepared for the realities of nursing and to be more ready to meet the working life.