Novel Nurses Perception of Role Transition from Nursing Student to Practice Nurse in South East of Iran

Narjes Pourbahaaddini Zarandy¹, Farideh Razban², Esmat Noohi³, Esmat Noohi⁴

¹PhD Candidate in Nursing, Department of Nursing and Midwifery, Islamic Azad University, Kerman Branch, Kerman, Iran.

²PhD Candidate in Nursing, Nursing Research Center, Kerman University of Medical Sciences, Kerman, Iran

^3,4Assistant Professor, Department of Medical Education, Medical Education Development Center, Kerman, Iran.

*Corresponding Author Email: npbzarandy@yahoo.com

ABSTRACT:

Background and aim: The transition from nursing student to practice nurse is stressful, challenging and dreadful process which can negatively effects on nursing care. This study was conducted to determine novel nurses' perception of role transition from nursing student to practice nurse.

Methods: In this cross-sectional study, all novel nurses who employed in hospitals supervised by Kerman University of Medical Sciences were recruited. Novel nurses’ perception of role transition was examined by NPRTS questionnaire. The data were analyzed by descriptive and analytic statistics and SPSS19 software.

Results: Findings showed that, 131 novel nurses who participated in this study, had perceived moderate level of simplicity (3.05 ± 0.64 from 5) during the process of role transition. The least perception of role transition ease were respectively related to the categories of Collegial Relationships (2.87 ± 0.77), Understanding of the Role by Clients (3.00 ± 1.03) and Confidence, Comfort, and Competence (3.19 ± 0.72). Nurses who graduated from Islamic Azad Universities, Nurses who had the chance to choose their work place and who pass orientation program, represent more perception of role transition ease compare to others.

Conclusion: This study confirmed that the two factors including “autonomy in selecting work place” and “passing orientation program” are related to the alleviation of role transition challenges. The other strategies that might enhance novel nurses’ sense of competence, confidence, and belonging are pregraduational educations, students’ residency in hospital, interships programs, preceptorships or mentorships programs, and peer support.

KEYWORDS: Novel nurses, Perception, Role transition.

INTRODUCTION:

Transition is a process by which the individual exits from one stage of life and enters the other one. Role transition means to pass from one role to another and it will accompany with change of thought, behavior, and performance (1). Transition in nursing is a period in which newly graduated nurses involve learning, adaptation, and socialization process in their work place (2).

Role transition from student to practice nurse is stressful, dreadful, and challenging throughout the world (3). The novice nurses feel anxious, insecure, inefficient, and instability in clinical setting (4). Stress, anxiety, uncertainty may be due to lack of preparedness and confidence. Newly graduated nurses require time and experience to get self confidence, to take responsibility and critical thinking (5). Duchscher et al (4) stated that newly graduated nurses might get transition shock during role transition from student to practice nurse. They stated that this shock is due to the conflict between relationships, responsibilities, and knowledge and performance expectations among these two roles. After graduation and acceptance of their professional role, nurses enter a setting where there are different conditions and values compared to student settings. Many nurses when starting their work in practice find that the expectations of the organization are not in accordance with their abilities. They notice that the values and ideals of academic environment are inconsistent with clinical setting (6). Clinical setting is not predictable so it is different from student environment. For this reason, novice nurses while they are trying to provide safe care for the patient may experience a high level of stress (7).

Non-optimal experience during role transition from student to practice nurse can delay the nurses access to their complete potential (3). Individuals who feel that challenges of this period cannot be tolerated may leave the nursing profession or they leave their first profession within less than 12 months (8). As a result, nursing shortage will be exacerbated and the cost and services spent on education of nursing students will be wasted. Transition shock can affect negatively on nursing care due to stress, conflict, and improper expectations (9). Insufficient preparedness of nurses at the beginning of practice may put the patients' safety at risk (7). In order to overcome the negative effects, strategies have been proposed. These strategies increase self-confidence and quality of novice nurses’ performance and decrease their anxiety. Such strategies include formal and informal approaches like graduation programs, residency programs, orientation programs, nurse internship, lecturer practitioner support, peer support, mentorship, and perceptorship (3).

In Iran, only three qualitative studies were found that have investigated novice nurses' experience of role transition. In 2013, Zamanzadeh et al extracted subthemes including lack of practical skills, limited academic knowledge, inadequate social skills, poor self-confidence, lack of independence, frustration, stress, and loneliness were emerged (15). Hezaveh et al., in 2013, found three themes including functional disability, communicative problems, and managerial challenges. In this study, the participants indicated inability of novice nurses for applying their learned knowledge in practice (10). Also, four themes extracted from the study of abedi et al., including professional competency, self-esteem, colleagues' expectations and emotional distress. Research findings showed that most of participants had experienced lack of preparedness for entering work setting (11).

In 2010, Deasy et al conducted an exploratory study in Ireland to compare novice nurses’ perceptions and expectations of role transition pre and post-registration. Respondents had high levels of confidence in clinical abilities both at pre-registration and post-registration. They also perceived themselves to be competent across a range of domains including managing workload, prioritising care delivery, interpersonal skills, time management and multidisciplinary team working (12). In 2014, Lee et al conducted a descriptive study in Korea to identify the perception of role transition from a student nurse to a registered nurse among senior year nursing students. The participants perceived relatively smooth role transition (13).

In the context of Iran newly graduated nurses are obligated to work in governmental hospitals for two years, in order to complete their commitment and get nursing degree, hence currently more than half of nurses who are working in hospitals are novice nurses. Considering high population of novice nurses in Iranian hospitals, their performance not only affect the future of the hospitals but also is effective on quality of care at the present time. According to personal experiences of researchers, novice nurses seems to have a high level of stress when starting to work in hospitals. But there is a lack of quantitative study in this regard in Iranian context. Hence, this study was conducted to determine novel nurses perception of role transition from nursing student to practice nurse in South East of Iran.

METHODS:

In this descriptive cross-sectional study, after getting permission from Islamic Azad University of branch of Kerman, Kerman University of Medical Sciences and heads four hospitals supervised by Kerman University of Medical Sciences, the data were collected from these hospitals. Information were gathered during four months (from August to November, 2015) in these hospitals. After explaining the aims of the study, research questionnaires were given to nurses.

Novice nurses who have had less than two years of nursing experience were included in this study. The novice nurses were introduced by head nurse of each ward and the questionnaires were given to them in work hours. The nurses were autonomous to participate in this study. Census sampling was done due to low number of such nurses. Therefore, the questionnaires were given to all such nurses in four hospitals affiliated to medical science university (Shafa, Shahid Bahonar, Afzalipour, Shahid Beheshti).

INSTRUMENTS:

Background information:

Background information included items that according to researchers could affect views of nurses on role transition from student to practice nurse. It comprised of three aspects: A) personal characteristics such as age, gender, marital status B) educational background such as level of education, the university where the nurses were graduated, total average Bachelor of Science score C) information related to the start of nurse practice role such as passing orientation program, having the chance of choosing the ward, methods of labour division

Nurse practitioner role transition scale (NPRTS):

This scale designed by Strange in 2015 in United State to evaluate nurses perception of role transition from nursing student to practice nurse (14). Strange has completed three studies (two quantitative studies and one qualitative study) to design and validate the scale. In the two quantitative studies 182 and 427 nurses were studied separately. Information obtained from these researches was factor analyzed. Subsequently, a qualitative study was conducted on 70 neonatal nurses in order to modify the questionnaire.

The final version of NPRTS consisted of 18 items and three areas including 1) role confidence, comfort, and competence; 2) collegial relationships; and 3) understanding the role by clients. The responses were formulated based on Likert five point scale (from completely agreed to completely disagreed). The lowest score of NPRTS was 1 and the highest ones was 5.

Forward and backward translation has been applied to translate NPRTS from English to Persian. Items were translated independently by two specialized translators. Then, a draft of this questionnaire was provided. It was re-translated into English and after final matching, the main copy was prepared. A pilot group of 10 novice nurses from the study were asked to read the translated questionnaire and make their comments on it and their suggestions were applied. In Iran, no study was found that assessed the reliability and validity of this scale. Therefore, the validity and reliability of the questionnaire were re-evaluated. The questionnaire was given to ten faculty members of nursing and midwifery school in order to assess its' content and face validities. Also they checked the the content of the questionnaire in terms of cultural aspects and their suggestions were applied. Content validity index of the questionnaire was 0.97. The reliability of the questionnaire was studied by conducting a pilot study on 20 novice nurses and Cronbach alpha was calculated as 0.85.

Statistical analysis:

The information of the questionnaires was analyzed using statistical package for social scientists (SPSS) 20 software. Kolmogorove-Smirnov test indicated that data distribution has been normal. Descriptive (relative and absolute frequency, mean, and standard deviation) and analytic statistics (independent T test, ANOVA) were used for analyses. The significance level was considered as 0.05.

RESULTS:

Background information:

131 novice nurses participated in the research. As seen in table 1, most nurses participated in the research were female (81.5%), married (50.4%) and were aged from 20 to 25 years (75.5%). Most of them had Bachelor of Science (B.Sc) in nursing degree (97.7%) and their total average Bachelor of Science score was between 17 and 20 (53.1%). Most of them had worked in one of medical-surgical wards after graduation. About half of nurses had lower than one year nursing experience (49.0%) and half of them had nursing experience between one and two years (51.0%). 67.7% of nurses stated that they had not the chance of chossing their work place when starting their nurse practice role. More than half of nurses (59.2%) stated that they would choose CCU, ICU, NICU, and dialysis wards if they had the opportunity to choose their work place. Majority of nurses (68.2%) reported that the orientation program was held for them at the beginning of their practice role. 45.0 % reported that the duration of orientation program was less than one week and 26.7% indicated that the program was held during one or two weeks. Commonly, the head nurse (44.2%) or one of experienced nurses who was working in that ward (48.8%) was responsible for orientation of novice nurses. Most nurses participated in this research (60.7%) expressed that method of labour division in the ward was done by case method.

Descriptive findings:

In present study, the score between one and five has been allocated to perception of novice nurses about role transition from student to practice nurse. Higher score reflected more ease in role transition ease and a lower score indicated less ease in role transition. According to table 2, novice nurses participated in present study perceived an average level (3.05±0.64) of ease in process of role transition. Most difficulties in process of role transition respectively associated with the categories of “collegial relationships” (2.87± 0.77), “understanding of the role by clients” (3.00±1.03), “role confidence, comfort, and competence" (3.19±0.72). the most difficulties perceived by novice nurses in process of role transition associate with items of "I felt that I was supported by my physician colleagues." (2.52±1.15), "I felt I got a lot of support." (2.76±1.012) and "I was treated as a professional by my colleagues" (2.77±1.07). The items in which novice nurses perceived the most ease in process of role transition are "I felt very competent managing my patient case load." (3.53±0.92), "I was able to complete my responsibilities in the allotted time because I was comfortable with my skills." (3.35±0.96) and "I felt I had the skills to deal with role transition." (3.35±1.09).

Table 1: background information about novice nurses

Variables

Number

Percentage

Age

20-25

26-30

> 30

75.5

22.1

2.4

Gender

Female

Male

106

81.5

18.5

Marital status

Single

Married

49.6

50.4

Education Level

Bachelor of science

Master of science

127

97.7

2.3

Years of nursing experience

Less than one year

Between one and two years

49.0

51.0

Have you chosen the place of your work?

Yes

32.3

67.7

Have you passed the orientation program at the beginning of practice role?

Yes

68.2

31.8

If yes, how many days has it taken?

Less than one week

Between one and two weeks

Between two and three weeks

More than three weeks

45.0

26.7

9.8

18.3

If yes, who was responsible for training you?

Supervisor

Head nurse

Expert nurse

7.0

44.2

48.8

Method of labour division

Case method

Team work

60.7

39.3

Table 2: perception of novice nurses about role transition from student to practice nurse

Categories	Items	Mean (SD)
Self-confidence, simplicity and qualification of role play 3.19 (0.72)	1- I feel self-confident as a nurse	3.06 (1.06)
	2- it is easy for me to care patients	3.08 (1.01)
	3- I feel qualified in taking responsibilities related to care of patient.	3.53 (0.92)
	4- I feel comfortable in my role as a practice nurse	3.19 (1.05)
	5- I can finish my responsibilities in determined time because I feel comfortable with my skills	3.35 (0.96)
	6- I make decision confidently	3.26 (1.05)
	7- I felt that role transition from student to practice nurse was easy	3.09 (1.11)
	8- I feel that I have essential skills for adaptation with role transition from student to practice nurse	3.35 (1.09)
	9- University educations have prepared me for role transition from student to practice nurse.	3.04 (1.09)
Relationship with colleagues 2.87 (0.77)	10- I felt that I was supported by doctors	2.52 (1.15)
	11- my work relationship with doctors is based on cooperation	3.01 (1.04)
	12- I feel that I have a good relationship with doctors	2.97 (1.13)
	13- my colleagues behave me as a professional nurse	2.77 (1.07)
	14- I feel that I am supported well	2.76 (1.12)
	15- other persons of treatment team respect me	3.14 (1.07)
	16- I Felt that management supported me	3.02 (1.13)
Perception of clients from the role of practice nurse 3.00 (1.03)	17- I feel that my role as a practice nurse has been perceived well by the society	2.95 (1.08)
	18- I feel that my role as a practice nurse has been perceived well by patients and their families	3.08 (1.18)
Total	3.05 (0.64)

Table 3: the relationship between background information of novice nurses and their perception from role transition from student to practice nurse

Dimensions of role transition

Background information

Self-confidence, simplicity and qualification of role play

Relationship with colleagues

Perception of clients from the role of practice nurse

Total

Education level

Bachelor of Sciences

Master of Sciences

3.22 (0.70)

2.00 (0.66)

t=2.98

P=0.003

2.87 (0.77)

2.76 (1.10)

t=0.25

P=0.80

2.99 (1.039)

3.16 (1.04)

t= -0.28

P=0.77

3.06 (0.63)

2.42 (0.71)

t= 1.70

P=0.09

The chance of choosing the ward

Yes

3.36 (0.70)

3.12 (0.71)

t=1.75

P=0.08

3.09 (0.76)

2.78 (0.76)

t= 2.11

P=0.03

3.08 (0.95)

2.97 (1.07)

t= 0.58

P=0.56

3.22 (0.61)

2.97 (0.63)

t= 2.10

P=0.03

The pass of orientation program

Yes

3.33 (0.66)

2.93 (0.77)

t=3.01

P=0.003

3.04 (0.69)

2.55 (0.86)

t=3.43

P=0.001

3.09 (0.99)

2.81 (1.09)

t=1.43

P=0.15

3.19 (0.56)

2.77 (0.70)

t=3.61

P=0.000

DISCUSSION:

The aim of this study was to examine the perception of novice nurses about the process of role transition from student to practice nurse in South East of Iran. Findings indicated that novice nurses participated in present study perceived an average level of ease in the process of role transition. In this regard, in a study conducted by Deasy et al (12) in Ireland, more than half of novice nurses (59.44%) stated that they have passed the process of role transition successfully. Nurses perceived the highest ease in the category of “role confidence, comfort, and competence” and items of “I felt very competent managing my patient case load.” and “I was able to complete my responsibilities in the allotted time because I was comfortable with my skills”. Deasy et al (12) also reported in their study that novice nurses had high level of self confidence in management of their work, priorities of cares and time management.

The most difficulties in the process of role transition associated with the category of "collegial realtionships” and three items including “I felt that I was supported by my physician colleagues.”, “I felt I got a lot of support.” and “I was treated as a professional by my colleagues”. Consistently, Mooney et al (15) conducted a qualitative study in Ireland and reported that most novice nurses had not got sufficient support. In a study conducted in Iran by Zamanzadeh et al (16), novice nurses experienced no support from their colleagues. In this qualitative study that addressed experience of novice nurses in the process of role transition from student to practice nurse, researchers stated that. When nurses started to work at hospitals encounter a setting which was very different from university setting. Since this unfamiliar setting was not supported by managers and colleagues, novice nurses felt loneliness and alienation resulting in increase of their stress and challenge. Similar to results of the present research about lack of sufficient support of physicians, in

a qualitative research done by Atashzadeh Shourideh et al (17), nurses stated that physicians feel they are superior to nurses and behaviors resulted from this view lead to relationship problems between the physician and the nurse. They go on that there is a strict hierarchical relationship between the physician and the nurse in Iran and the position of physicians is superior to the nurses. Most physicians in hospitals are male and most nurses including those who participated in the study (81.5%) are female and traditional attitudes towards the role and relationship between man and woman encourage the physicians to behave strictly and to dominate on nurses.

As mentioned before, "I was treated as a professional by my colleagues” has been one of three items that were perceived by novice nurses with highest difficulty in the process of role transition. Contrary to present study, in a qualitative study that conducted by Kumaran et al (18) in Ireland, novice nurses stated that they had been ignored by their colleagues when they were students, but after graduation and starting practice nurse role, the attitude of their colleagues especially physicians had changed to them. The particiapnts of study, expressed that they receive much consideration from their colleagues at the beginning of their nurse practice role. Findings of the present research indicated that 67.7% of nurses did not choose their work place at the beginning of their nurse practice role. The nurses who chose their work place at the beginning felt more ease in the category of “collegial relationships” and in the total score of NPRTS compared to others. Whitehead and Holmes (19) proposed that the right for choosing the ward facilitated the role acceptance. They go on that nursing students who choose the work place of their internship program and continue to work at the same place after graduation will experience more ease of role transition (20).

68.2% of novice nurses reported that they passed orientation program at the beginning of their nurse practice role. These nurses, perceived more ease in the category of “role confidence, comfort, and competence”, “collegial relationship” in the total score of NPRTS compared to others. In this direction, Crimlisk et al (20) stated the 72% of nurses who passed orientation program felt more ability and competency for patient care. Floyd et al (21) reported that 77% of novice nurses felt more self-confident and awareness after orientation program. In a review study, Edwards et al (3) concluded that orientation program leads to feel of qualification, capability and awareness and such nurses stay on their profession for a longer time period.

CONCLUSION:

Research findings suggest that students after graduating and starting nursing practice role had perceived an average level of difficulty. Results indicated that choosing the place of work and passing orientation program can reduce difficulties and challenges of role transition from student to practice nurse. In this regard, other formal and informal strategies can be proposed to increase feel of qualification, self-confidence, and adherence to clinical setting. Among formal strategies, educations before graduation, the residency program and internship program can be referred to. Educational programs of mentorship and perceptorship and peer support are among informal strategies. Review of literatures showed that the effect of implementation of such strategies on the process of role transition from student to practice nurse has not been studied in Iran. Therefore, it is suggested that the effect of proposed methods on the process of role transition from student to practice nurse study in future researches.

ACKNOWLEDGMENTS:

The authors would like to appreciate research Vice-President of Kerman Branch of Islamic Azad University for funding and supporting this project. The authors also thank to all hospital staff who kindly participated in this study.

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Received on 13.11.2016 Modified on 16.12.2016

Asian J. Nur. Edu. and Research.2017; 7(3): 357-362.

DOI: 10.5958/2349-2996.2017.00071.4