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Running head: TRANSITION FROM STUDENT TO NURSE 1

The Transition from Student Nurse to Registered Nurse

Nicole E. McDonald

Ferris State University

TRANSITION FROM STUDENT TO NURSE 2

Abstract

Transition shock is a phenomenon felt by new nurses making the transition from student nurse to

licensed registered nurse. It occurs when ones perception of nursing does not match up with

their experiences in entering the profession. The main reasons for this problem are high patient

to nurse ratios, inadequate staffing, orientation periods being cut short and lack of support from

peers, supervisors and employment organizations. This issue is examined in regards to a nursing

theory and an interdisciplinary theory, and its relationship with both. An assessment of the

current healthcare environment is completed. Research regarding means for improvement, for

example nurse residency programs and leadership programs, are investigated, and suggestions

for improvement are made. Quality and safety measures are also considered. The purpose of

this paper is to consider the many factors that play in to reality shock, determine what is being

done to reduce it, and discuss what else can be done to improve the transition for future cohorts.


The Transition from Student Nurse to Registered Nurse

As a student nurse reaches the end of a nursing education program, he or she is faced

with taking and passing the National Council Licensure Examination for Registered Nurses

(NCLEX-RN), finding a job, adapting to the change from student to practice with a preceptor

and then practice independently. This process comes with a lot of unknown, and often

unexpected, situations. The difference between what a student nurse expects going into the

nursing work force, and what it is actually like, are usually quite different and this concept is

known as reality shock (Casey, Fink, Jaynes, Campbell, Cook & Wilson, 2011). The current

nursing shortage in the United States is of serious concern in the healthcare field, and according

to MacKusick and Minick (2010), is projected to reach over 500,000 nurses by the year 2025.

Education, hiring of and retention of new nurses is of high importance in healthcare facilities, but

due to the stressful transition period from being a student to a new working nurse, almost half of

new nurses consider leaving practice within the first year, and between 30% and 50% actually do

leave the profession within the first three years (MacKusick & Minick, 2010). Up to 50% of

currently practicing nurses would not recommend nursing as a career and 25% would actively

discourage going into nursing (Duchscher, 2009).

Nursing Theory

The Transition Shock Theory by Judy E. Boychuk Duchscher (2009) examines the

contrast in four areas: knowledge, responsibilities, roles and relationships between student and

new nurse. Duchscher (2009) states that this transition shock occurs in varying intensities from

the first day on the job, and can last past orientation. Most nurses in this study never thought

their experience as a new nurse would be negative, or that their new work environment would

feel unwelcoming, but many described them that way (Duchscher, 2009). Responsibility


changes can come in the form of utilizing and being part of the interdisciplinary team, working

more with families of patients, newfound leadership and the ability to delegate, as well as trying

to balance work and home life (Duchscher, 2009). Knowledge changes include expected

increase in knowledge and skill as a professional, finding a balance between personal and

professional self, and trying to combine intellectual, practical and theoretical knowledge

effectively. Role changes stem from having newfound autonomy, developing as a professional,

trying to modify oneself from a previous role, balancing the roles of friend, spouse and nurse,

and adapting to the change from student to Registered Nurse (RN). Relationship transitions

include expectations of leadership and collaboration, support from peers, maintaining personal

and professional relationships while keeping them separate, and dealing with other life changes

as well (Duchscher, 2009). According to the Transition Shock Theory, reality shock occurs

when these changes are taking place and the new nurse experience feelings of doubt, confusion,

loss and disorientation (Duchscher, 2009). See Diagram 1 in Appendix A.

Duchscher (2009) described that these feelings of doubt, confusion, loss and

disorientation could be expressed physically, emotionally, intellectually and socio-

developmentally (Duchscher, 2009). Physical expressions of transition shock can manifest due

to adjustment to shift work, interrupted sleep, poor nutrition, lack of exercise and changing social

habits or everyday routines. Emotional changes can include labile moods, intense or

overwhelming emotions, need for validation and reassurance, seeking protection, fears of failing

or disappointing others, loss of control and support. Intellectual manifestations are caused by

assumed vs. actual practice expectations, lack of awareness of the transition, low practical

knowledge, being unfamiliar with the facility, role immaturity and low feedback on performance.

Socio-developmental expressions can be from role uncertainty and unfamiliarity, lacking


guidance, newness to the professional realm, how to utilize interdisciplinary relations, pressure

to be a leader and delegate and gaining independence (Duchscher, 2009). Being aware of these

role changes and the ways in which they can manifest may help the new nurse work through the

transition, and lessen the reality shock that he or she feels. See Diagram 2 of Appendix A.

Interdisciplinary Theory

Dr. Nancy Schlossberg’s Theory of Transition is a psychosocial theory used to help

people work through transitions, and learn what factors can affect how well one adjusts to

change (Anderson, Goodman & Schlossberg, 2012). This theory discusses four major concepts

that influence one’s ability to cope with change: situation, self, support and strategies, known as

the four S’s (Anderson et al., 2012). Situation includes whether or not the change was expected,

if the change is coming at a time with many other stressors, and if the change is viewed as

positive or negative (Andersonet al., 2012). The second S, self, includes whether or not the

person is in good health, if there is a positive or negative outlook on the change, the strength of

the commitment to the change and how resilient that person may be (Anderson et al., 2012).

Support, the third S, includes friends, family, a spouse, peers, supervisors and the organization,

and the level of support from each of these (Anderson et al., 2012). Strategies to cope with

change depend on what situations someone has been through, coping mechanisms used in the

past and how well those strategies worked (Anderson et al., 2012).

Assessment of the Healthcare Environment

A study by Casey et al. (2011) identified that some factors influencing reality shock are

fast pace, changing technology, and expectations that new graduate nurses will take on large

numbers of patients with high acuity needs. This study also found that new nurses do not feel

prepared to work in the understaffed environments they encounter (Casey et al., 2011).


According to Hartigan, Murphy, Flynn & Walshe (2010), the expectations of newly educated

nurses are higher now than ever before. This can play an important role on the severity of the

reality shock new nurses feel upon entering the field, as this increases the pressure felt in early

stages of employment and training. Nearly all new nurses lack the confidence and leadership

necessary for nursing practice, because it takes experience to develop proficiency in those skills.

There are few organizations with programs in place to assist new graduate nurses with the

transition from education into nursing practice. After much observation in the clinical setting, it

seems that current practices are to educate student nurses, often in accelerated programs, hire and

train as many as possible, provide a minimal orientation period to cut costs, with a preceptor that

may or may not want to teach and then give independence and a full patient assignment with

expectations there will be success. In a career with such high stakes, and with patient’s lives on

the line, training of new nurses should be of high priority to other nurses, nurse supervisors and

physicians as well, in order to promote a high quality level of care.

In a study by MacKusick and Minick (2010), in which non-practicing RNs were

interviewed, there were three main reasons why RNs left practice: unfriendly workplace,

emotional distress, fatigue and exhaustion. New RNs experienced being ignored, feeling alone,

being belittled, told to toughen up, and an overall lack of support (MacKusick & Minick, 2010).

Several new RNs reported instances of hazing and verbal abuse, and reported managers ignoring

or turning a blind eye to the behavior (MacKusick & Minick, 2010). The nurses that tried to

intervene in these behaviors received little to no support by peers and supervisors (MacKusick &

Minick, 2010). Nurses in this study complained of feeling emotional stress due to aggressive

behavior by physicians with little regard to the rest of the interdisciplinary team, and a low level

of respect from physicians for patients and families, especially at end of life. One Neonatal


Intensive Care Unit (NICU) nurse discussed her experiences of keeping babies alive with

technology, which would never survive long term, and reported having negative feelings about

providing these parents with false hope (MacKusick & Minick, 2010). These negative feelings

about nursing roles increased emotional stress, leading to more call-ins and increased

consideration for quitting (MacKusick & Minick, 2010).

The nurses in the study by MacKusick and Minick (2010) reported feeling emotionally

and physically exhausted most of the time, and unsupported, lonely and exhausted. These are

conditions which very quickly lead to burnout. The task of constantly being responsible for

major, important patient decisions was emotionally exhausting; some of the nurses described

never being able to turn their brains off, even away from the hospital (MacKusick & Minick,

2010). New nurses in a study by Pellico, Brewer and Kovner (2009), experienced the same

feelings of low support and lack of communication with physicians. In this study, turn-offs to

the nursing career included feeling let down by the career because of high expectations, being

pushed through orientation and into independence before feeling ready, high physical and mental

demands and verbal harassment from physicians. In this study 37% of responders wanted to

change jobs (Pellico et al., 2009). There were discrepancies between what new graduatess

believed nursing would be like and what it really was like. The differences involved lacking a

voice, as well as high nurse to patient ratios with high acuity patients with little difference in

assignments compared to experienced nurses (Pellico et al., 2009).

According to Pellico et al. (2009), new nurses felt rushed through orientation and out on

their own with a full, high acuity patient load and not enough time to provide quality care or any

extended amount of time to complete skills that took them longer as novice nurses (Pellico et al.,

2009). New nurses also complained of high levels of physical and emotional stress, reporting


they often could not take a break and hardly had enough time to go to the bathroom (Pellico et

al., 2009). Another factor that makes new nurses feel rushed is the extensive documentation. As

a new nurse is trying to care for patients, learn the policies of a new facility and adjust to the

change in role, he or she is spread quite thin. With the addition of learning a documentation

system and becoming proficient in it at the same time, it is not surprising that new nurses are

becoming overwhelmed. Long shifts, working weekends and holidays, overtime, and not having

adequate time to complete all tasks within the shift, are all reasons for nurse burnout and

contributors to low nurse retention (Pellico et al., 2009).

Many of the nurses interviewed in the study by Pellico et al. (2009) also experienced

horizontal hostility among their peers, vertical hostility from physicians and supervisors, and

65% had experienced verbal abuse as a new nurse. New nurses described the concept that

experienced nurses do “eat their young” is very real, and many of them voiced experiences of

harshness and belittling from physicians and experienced nurses, but also from their own

preceptors (Pellico et al., 2009). Some of these nurses experienced negative behavior from

management as well, for example being given a difficult assignment and then disciplined for

staying late and obtaining overtime, with no consideration to novice status (Pellico et al., 2009).

Inferences, Implications and Consequences

Considering all of these experiences as contributors to decreased nursing retention and

decreased job satisfaction in the field of nursing, this can lead to decreased quality work

environments and thus, decreased quality of care. There is strong evidence linking high quality

practice environments to increased patient outcomes, patient safety, nurse recruitment and nurse

retention (Dyess & Sherman, 2011). The most important part of nursing is providing quality

patient care. In a study by Berry, Gillespie, Gates and Schafer (2012), nurses who experienced


even one instance of workplace bullying showed an increase in work productivity. When a new

nurse works in an environment where workplace bullying occurs, he or she is at an increased risk

for exhaustion and eventually burnout (Berry et al., 2012). This behavior puts patients in an

environment in which ineffective care takes place (Berry et al., 2012), When new nurses are

faced with workplace violence, their cognitive abilities are compromised as well as their abilities

to handle higher patient assignments (Berry et al., 2012). A nurse who is scared to talk to his or

her patient’s physician may miss vital information about the patient’s status, opportunities to

discuss care modalities for that patient, or may not speak up and advocate for that patient out of

fear of being bullied (Casey et al., 2011). The nurse may not ask a peer about a care modality

out of fear that peer will think he or she is not smart enough to make that decision independently.

New nurses who felt disrespected and unappreciated, also reported feeling frustrated and

unhappy with their position as an RN (Pellico et al., 2009). One nurse reported being

disappointed day after day of coming to work, and had come to hate his job as an RN (Pellico et

al., 2009). These types of feelings may be obvious to peers, supervisors and patients, which

could lead to decreased patient satisfaction. Decreased job satisfaction leads to a decreased

quality of work, increased stress at home and work, can increase stress and anxiety and will

eventually lead someone to find a different job or line of work (Duchscher, 2009). If a new

nurse is displaying a decreased quality of work, this could lead patients to feel like they are not

being adequately cared for and this could lead to decreased patient satisfaction ratings as well.

When a new nurse, with little confidence, is given a high patient load every day and is

continuously unable to meet the expectations well, he or she may become discouraged. New

nurses who are discouraged are less likely to want to get better and more likely to leave the field

(Pellico et al., 2009). If a new nurse is unable to take a lunch break, sit down or even have


adequate time to use the restroom on a regular basis, burnout is inevitable and quickly, and these

factors are compounded even further when there are staffing issues.

When a new nurse has a preceptor who does not want to teach them, makes them feel

inadequate or is not supportive, he or she will quickly become turned off to the profession and

may find themselves looking for a new position. Nurses who “eat their young” are intimidating

and miserable to be around, and if a new nurse has a preceptor like this, whom he or she spends

large amounts of time with, that new nurse may feel they have chosen the wrong career. Being a

new nurse, this person may not know how to handle the conflict or work through it, and may feel

like he or she has no other choice but to leave (Pellico et al., 2009). Most facilities require new

nurses to report these types of problems to their supervisors, but in many facilities, the new

nurses did not report due to fear of retaliation, or the supervisors ignored the reported issue and a

large contributor to low nurse retention rates and decreased job satisfaction for new nurses.

Another issue is cost, and according to Pellico et al. (2009) turnover can cost a facility

between $10,000 and $60,000 per new nurse, which is not effective for the nursing profession,

hospitals or the healthcare system as a whole. Turnover rates vary greatly by facility, and can

range up to 70% in some facilities (Pellico et al., 2009). Many modifications could be made to

improve nurse retention and decrease costs related to turnover. Orienting a new nurse is

expensive, it is like paying two nurses to do the job of one, and if a facility or department is

already short-staffed, this can contribute to the issue. Due to problems like this, nurse managers

are pushing new nurses through orientation more quickly, so they are able to assist with staffing

crises and increased patient care demands (Pellico et al., 2009). This type of process, while

maybe cost effective, is unsafe and could contribute to decrease in knowledge of new nurses,

decreased confidence, increased risk for errors and again that decreased quality of patient care.


Progress is being made in improving these aspects of the transition, but much more is needs to be

done. Being aware is the first way new nurses can improve this experience for themselves.

Recommendations for Quality and Safety

Considering the issues, now the goal is to determine what can be done to change these

negative experiences and improve nurse retention. MacKusick and Minick (2010) found that in

order to improve the role of being a nurse and decrease burnout, efforts should focus on

improving the work environment, including the support system and staffing conditions.

Horizontal hostility and lack of supervisor support were top reasons for leaving nursing.

Implementation of programs to support burned out and overly stressed nurses are needed to keep

the experience in the field of nursing, and decrease exhaustion nurses feel (MacKusick &

Minick, 2010). Full support programs for new nurses are essential, as this transition is where the

trend begins. If a new nurse knows he or she will have a network to turn to when difficult

situations arise, he or she will not have that fear of feeling alone. Strict policies regarding

horizontal hostility are vital to improving these conditions, and in retaining new nurses

(MacKusick & Minick, 2010).

New nurses interviewed in the study by Pellico et al. (2009) stated that being checked off

on skills in the clinical setting would be much more beneficial and instill much more confidence

in students than being checked off on a manikin in the lab. These nurses also recommended

more hands on clinical time to improve the correlation between expectations and reality (Pellico

et al., 2009). When it comes to obtaining a job and orienting to a position, new nurses in this

study also recommended longer time with a preceptor, more guidance with clinical decision-

making and judgment, and suggestions for skill improvement. Recommendations also included

extra support with delegation, conflict resolution and overall guidance (Pellico et al., 2009).


It is important for new to nurses be aware of transition shock, what causes it, and

methods that can be used to get through it. Preceptors to new nurses must also be aware of this

problem, and be educated in how to help make the transitions less negative, and help promote

success. This concept is also important for nurse managers, as they are the ones who schedule

orientation and training; monitor the new nurse’s strengths, weaknesses and readiness for

independence. Nurse managers must be educated on methods of training and educating new

nurses, to improve feelings of adequacy and foster a smoother transition into the field.

A study by Casey et al. (2011) found that nursing students who had a final course

emphasizing leadership and management, communication, conflict management,

interdisciplinary collaboration and information technology, had increased confidence in their

first nursing job. This research promoted a senior practicum including all these aspects and

utilized the last semester of the education program to practice these skills (Casey et al., 2011).

This study also discussed the importance of simulation experiences in providing opportunities for

nursing students to practice their skills in life-like situations before facing them on the job

(Casey et al., 2011). Clinical simulation experience is associated with better transition periods

for new nurses and higher levels of confidence entering the workforce (Casey et al., 2011).

Research by Dyess and Sherman (2011) found data on the Novice Nurse Leadership

Initiative (NNLI) which began in South Florida in 2006. The NNLI is a ten month program

comprised of twenty sessions to provide support for the new nurse during the first year of

practice (Dyess & Sherman, 2011). This program also incorporated a nurse mentor to decrease

isolation that new nurses can feel, and focused on communication and conflict resolution (Dyess

& Sherman, 2011). During this program, new nurses examined issues in his or her departments

and chose one to research, and find evidence-based interventions to improve (Dyess & Sherman,


2011). This provided new nurse’s experience with leadership, research, and implementation of

policies for improvement of the working environment. Findings after several years of this

program concluded that consistent preceptors, extended orientation periods, opportunities to

meet with other new nurses and nurse leaders were valuable experiences in easing the transition

into nursing (Dyess & Sherman, 2011). This program is highly recommended by the Institute of

Medicine and the American Organization of Nurse Executives (Dyess & Sherman, 2011).

Nurse residency programs are gaining popularity among new nurses as well, and serving

as a way to ease the transition. One study by Bratt (2013) focused on a nurse residency program

in Wisconsin which started in 2005. This program was completed in addition to standard

orientation and lasted through the first year of employment. The program consists of education

and psychosocial support in the form of active learning and role playing focused on clinical

judgment, common clinical disorders and communication with physicians (Bratt, 2013). After

several years, results show that facilities which utilize these programs have higher new nurse

retention rates, decreased nurse vacancy and decreased spending on recruitment and turnover

(Bratt, 2013). New nurses who participated in a nurse residency program experienced improved

working environments, better relationships with peers and supervisors and decreased feelings of

reality shock (Bratt, 2013). This study also assessed the process of implementation of a nurse

residency program which includes, securing funds, obtaining and training staff, researching

evidence for basis of the program, and show benefits to attract participants (Bratt, 2013). These

processes are time-consuming and costly, contributing to the current lack of these programs.

Other programs that could be utilized to ease the transition for new nurses might include

simple networking programs for new nurses within facilities, providing opportunities for them to

reach out to each other with personal experiences, coping and as a means of support for one


another. Facilities could provide periodic education regarding support of new staff members,

targeting this education to nurses that work alongside new nurses, as well as nursing supervisors.

A program like that may decrease the amount of bullying new nurse’s experience and could

provide extra support and encouragement from peers and managers. As discussed, one

complaint of new nurses is lack of feedback regarding personal performance, so facilities could

begin a periodic assessment of new employees by peers and managers.

Despite all the negative data gathered from the study by Pellico et al. (2009), this

research also found that these issues are improving. One nurse reported that it takes one full year

to become comfortable in the new environment as a new nurse, and that one year is difficult, but

that it does get easier and the difficult times become less (Pellico et al., 2009). Now that these

issues are coming to the forefront, more action is being taking by nurses and supervisors and

hospital administration, to improve these conditions and the transition overall. With these

concerns, it is not surprising that the nursing shortage is so prevalent, and it is obvious that

without significant changes, these conditions and new nurse retention will not improve.

A common theme in the research was a need for more unity and cohesiveness between

nurses and that working as a team instead of against each other is necessary (Pellico et al., 2009).

New nurses stated some changes that could make the transition easier would be daycares at the

hospitals, longer orientation periods, implementing nurse residency programs, tuition

reimbursement, improved salaries, improved collaboration, utilizing nurse mentors, more

flexible scheduling, decreased patient to nurse ratios for new nurses, providing new nurses with

more of a voice and listening to their input, and stronger support from supervisors and

administrators (Pellico et al., 2009). There suggestions are helpful, but can be difficult and

expensive to implement. Over half the nurses that responded in this study had neutral or positive


transition experiences, so there is hope that conditions are improving. Many experienced nurses

are seeing the consequences of these negative experiences and moving into action to make

changes. Many nurses in the study by Pellico et al. (2009) vowed to work on making changes to

the work environment instead of being so quick to look for a new job or different place of work.

There was also a big push to listen to what new nurses have to say as they may have suggestions

that could make positive changes in the nursing profession and the transition period for new

nurses to improve retention.

Quality and Safety Education for Nurses

The Quality and Safety Education for Nurses (QSEN) project provides competencies in

which new nurses need to be proficient in to improve quality and safety of the practice

environment (Quality and Safety Education for Nurses, 2014). The competencies include

patient-centered care, teamwork and collaboration, evidence-based practice, quality

improvement, safety and informatics (QSEN, 2014). Implementing programs to ease the

transition into nursing will improve the competencies of teamwork and collaboration, and quality

improvement. Teamwork and collaboration would be improved by promoting open

communication between nurses, peers and supervisors, enforcing mutual respect, and

encouraging the new nurse to know his or her strengths or weaknesses (QSEN, 2014). These

programs would also encourage new nurses to utilize collaboration of the interdisciplinary team,

enforce acceptance of asking for help to advance education and improve skills, also to help new

nurses initiate conflict resolutions and assert their own opinions to advocate for patients

comfortably and confidently (QSEN, 2014). Implementing new nurse transition assistance

programs would advance quality improvement by monitoring program outcomes and providing

methods for improvement, encouraging new nurses to follow policies and procedures while


providing care, and enable nurse measure and evaluate new nurse performance (QSEN, 2014).

These programs would help facilities identify gaps in practice for new nurses, and provide

methods for improvement (QSEN, 2014).

American Nurses Association Standards for Professional Practice

The American Nurses Association (ANA) standards are expectations that nurses follow

while working as a professional nurse (American Nurses Association, 2010). Implementing new

nurse transition programs would relate to Standard 11: Communication, Standard 12: Leadership

and Standard 14: Professional Practice Evaluation. Communication is of the highest importance

when making the transition as a new nurse. New nurse transition programs would provide tips

for effective communication and conflict resolution, emphasize the importance of accurate

communication, encourage asking questions about physician orders, and would assist the nurse

in contributing his or her professional opinions about patient care (ANA, 2010).

Leadership is related to the changes because the programs would educate about

accountability, constantly improving and being a lifelong learner, respecting peers and on

effective communication and conflict resolution. Participating in these transition programs

would facilitate being part of a professional organization and would assist new nurses to increase

autonomy and accountability (ANA, 2010). New nurse support programs would provide tools to

help new nurses evaluate their own practice, allow open communication with peers and

supervisors for feedback, help new nurses apply evidence-based practice to confidently defend

their patient care decisions, allow new nurses to expand their knowledge, and would facilitate

feedback being given to experienced nurses to guide future interactions (ANA, 2010).


Conclusion

Making the transition from a student nurse to a licensed Registered Nurse can be a trying

and difficult time for new nurses as he or she learns about the new role and the responsibilities.

Having support from peers and supervisors, a complete orientation period with a preceptor who

wants to teach, appropriate patient to nurse ratios, guidance with clinical judgment and decision-

making, as well as networking with other new nurses are all factors important to making that

transition successful. Working through reality shock can be difficult, but with adequate

preparedness, the experience can still be a positive one. By implementing programs to help new

nurses successfully transition, new nurse retention rates can be increased, job satisfaction may

improve and strides can be made toward improving the nursing shortage. If current nurses can

make significant efforts to improve the process of transition for future new nurses, a change can

be seen and the idea of pursuing nursing as a career may become more desirable.


References

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Linking Schlossberg’s Theory with practice in a diverse world (4th ed.). New York, NY:

Springer Publishing Company LLC.

Berry, P. A., Gillespie, G. L., Gates, D., & Schafer, J. (2012). Novice nurse productivity

following workplace bullying. Journal of Nursing Scholarship, 44(1), 80-87.

Casey, K., Fink, R., Jaynes, C., Campbell, L., Cook, P., and Wilson, V. (2011). Readiness for

practice: The senior practicum experience. Journal of Nursing Education, 50(11), 646-

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graduated registered nurses. Journal of Advanced Nursing, 1103-1113

Dyess, S. M. & Sherman, R. O. (2009). The first year of practice: New graduate nurses’

transition and learning needs. The Journal of Continuing Education in Nursing, 40(9),

403-410

Hartigan, I., Murphy, S., Flynn, A. V., & Walshe, N. (2010). Acute nursing episodes which

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Practice, 10, 291-297. doi:10.1016/j.nepr.2010.01.005

MacKusick, C. I. & Minick, P. (2010). Why are nurses leaving? Findings from an initial

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Pellico, L. H., Brewer, C. S., & Kovner, C. T. (2009). What newly licensed registered nurses

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Appendix A

Diagram 1

Diagram 2

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