INTRODUCTION:

Transition from student to staff nurse can be difficult for nurses beginning their nursing career. Literature from Western reports that healthcare institutions often provide nurse residency program, a gold standard transition-to-practice program for new graduate nurses. Providing a nurse residency program is associated with a decrease in nurse retention(Letourneau and Fater 2015; Little et al. 2013; Trepanier et al. 2012). The nurse residency program improves not only retention rate, but also increases new nurse confidence, competence, and job satisfaction(Cochran 2017; AL-Dossary et al. 2014; Welding 2011).

Although literature supports the effectiveness of nurse residency program for the new nurses in the United State, there is no evidence in other developing countries on the implementation of such program. In Thailand, nursing shortage is a crisis situation. The hospital is hiring increasing numbers of nurses who are new graduates from various schools of nursing. Due to the acuity of hospitalized patients and the complexity of the acute care hospitals, it is impossible for even the very best school of nursing to prepare new graduates to work in today's acute care environment. Nurse residency program then is considered to be implemented in Thailand to facilitate transition-to-practice among new nurses. In order to provide nurse residency programs that are sensitive to the needs of new graduate nurses, it is important to know what they experience as they transition from student nurse to staff nurse during first year orientation. However, transition to practice experiences among Thai new graduate nurses is not well documented. The purpose of this study was to explore the transition experiences during the first year of practice among new nurses in Thailand.

MATERIAL AND METHODS:

A cross-sectional descriptive design using survey questionnaires was conducted to explore new nurses’ perceptions of their experiences during their first year of practice.

Sampleand Setting:

This study took place at a 1500-bed tertiary hospital in Bangkok, Thailand. The participants consisted of all nurses hired by the hospital during August 2015 to August 2016.Inclusion criteria were all newly hired nurses for the medical, surgical, pediatric, critical care and emergency, neurology, cancer, obstetrics andgynecology, operating room, and traumatic units. There were no exclusion criteria. The hospital employs approximately 178 registered nurses with varying nursing schools. The sample was obtained from the entire new hiring nurses of the hospital.

Instruments:

All participants completed the Thai version of revised Casey-Fink graduate nurse experience survey. The survey was created in 1999 and revised in 2002 and again in 2006(Casey and Fink 2009). The survey consists of 5 sections: demographic information; skills/procedure performance (3 open ended questions); comfort/confidence (24-items with Likert scale response with 1 = strongly disagree and 4 = strongly agree); 9 items on job satisfaction dimensions (5-point Likert scale ranging from 1 = very dissatisfied to 5 = very satisfied); and 4 multiple-choice questions about work environment and difficulties in role transition. Demographic data questions include age, gender, and area of working. The instrument takes approximately 15 to 20 minutes to complete. Forward and backward translations were performed to develop a Thai version of the survey. Three nursing experts participated in assessing content validity. The content validity index of the scale was 0.97. Internal consistency reliability was tested in 30 nurses. The overall Cronbach's alpha value was 0.80.

Ethical Consideration:

An official permission was obtained from the Director of Nursing prior to the study. No formal approval was required from the Institutional Review Board for Human Research due to the non-biomedical character of the study and it was considered as a quality improvement project of Nursing Department. The study was performed according to the Declaration of Helsinki. All participants received both oral and written information regarding the aim of the study. Return of a completed questionnaire was considered as consent to participate.

Procedure:

Data were collected using paper-and-pencil format on the new nurses’ final evaluation day. The meeting was set routinely as part of the orientation program of new nurses at the end of one year practice. The new nurses were gathered together in the meeting room and were asked to complete the surveys. The participants completed the surveys and the surveys were returned back at the end of meeting session.

Data Analysis:

Upon completion of data collection, data was analyzed using Statistical Packages for the Social Sciences (SPSS) computer software version. No identifying criteria were utilized. Statistical significance was set at p< .05. Descriptive statistics (percentages, frequencies, means, and standard deviations) was used to describe demographic data and answer the research questions.

RESULTS:

One hundred seventy eight surveys were distributed to new nurses. All of surveys were returned resulting in a 100%response rate. Most of the participants were females (n=167, 93.8%). Age ranged from 22-25years with a mean age of 23.4 years (SD 0.52). New nurses participating in the study were employed in critical care and emergency department (23.0%), medical department (21.3%), surgical department (16.9%), neurological department (10.1%), pediatric department (9.6%), obstetrics and gynecological department (9.0%), operating theater (5.6%), traumatic department (3.4%), and cancer units (1.1%).See Table 1for a complete demographic description of the participants.

Table 1Characteristics of the Participants (n=178)

Variable	Mean	SD	n	%
Age	23.4	0.52
Gender
· Male			11	6.2
· Female			167	93.8
· Area of working
· Critical care and emergency			41	23.0
· Medical			38	21.3
· Surgical			30	16.9
· Neurology			18	10.1
· Pediatric			17	9.6
· Obstetrics and Gynecology			16	9.0
· Operating room			10	5.6
· Traumatic			6	3.4
· Cancer			2	1.1

Skills and Procedures:

Section one of the surveys asks about skills and procedures that the new nurse felt uncomfortable performing independently during their first year of practice. The participantswere asked to choose three skills/procedures they felt uncomfortable performing from a list of 21 various skills/procedures.

Only 10.7% of new nurses were comfortable performing all skills and procedures. More than half of them (51.7%) reported performing code/emergency response as the first uncomfortable skill (see Table 2).

Ventilator care/management, EKG interpretation, chest tube care, and prioritization/time management were also the most frequently reported as difficult skills.

Table 2 Skills/Procedures New Nurses Felt Uncomfortable Performing (n=178)

Skill 1			Skill 2		Skill 3
Skill/procedure	n	%	n	%	n	%
Code/Emergency Response	92	51.7	25	14.0	16	9.0
Vent care/management	24	13.5	26	14.6	23	12.9
EKG	16	9.0	34	19.1	27	15.2
Chest tube care	11	6.2	36	20.2	17	9.6
Prioritization/time management	10	5.6	13	7.3	22	12.4

Confidence and Comfort:

Participants were asked to rank 24 statements evaluating their confidence/comfort level using a Likert scale with 1 = strongly disagree and 4= strongly agree.

The mean confident/comfort level for all 24 statements was calculated. The five statements that new nurses scored as being least confident in were “overwhelmed by my patient care responsibilities and workload”, “may harm a patient due to my lack of knowledge and experience”, “having difficulty organizing patient care needs”, “having difficulty prioritizing patient care needs”, and “making suggestions for changes to the nursing plan of care”. Table 3 shows mean and SD of all items.

Preceptor were perceived as the persons helping new nurses to develop confidence in their practice (mean 3.43, SD 0.56), and providing encouragement and feedback about their work (mean 3.45, SD 0.60)

Role Transition:

Participants reported on the types of difficulties they were experiencing during the first year of practice (see Table 4). Role expectation, lack of confidence, and workload issues were the highest rank of difficulty. These difficulties were reported by 78.1%, 64.6%, and 56.7% of the participants, respectively. Improve orientation (79.2%) and increase support (70.2%) was reported as the highest rank of support needed by the participants. While peer support was reported as the most satisfied work environment, interpersonal relationship was rank as the most dissatisfaction with work environment as perceived by new nurses.

Table 3 Confidence and Comfort (n=178)

Items	Mean	SD
I feel overwhelmed by my patient care responsibilities and workload.	2.55	0.71
I feel I may harm a patient due to my lack of knowledge and experience.	2.59	0.67
I am having difficulty organizing patient care needs.	2.60	0.54
I am having difficulty prioritizing patient care needs.	2.75	0.56
I feel comfortable making suggestions for changes to the nursing plan of care.	2.83	0.43
I feel the expectations of me in this job are realistic.	2.87	0.49
I feel comfortable delegating tasks to the Nursing Assistant.	2.89	0.42
I feel confident communicating with physician.	2.89	0.47
I am comfortable knowing what to do for a dying patient.	2.99	0.48
I am satisfied with my chosen nursing specialty.	2.99	0.65
I am able to complete my patient care assignment on time.	3.00	0.28
I feel comfortable communicating with patients and their families.	3.05	0.37
I feel prepared to complete my job responsibilities.	3.10	0.40
I feel at ease asking for help from other RNs on the unit.	3.13	0.50
I feel my work is exciting and challenging	3.17	0.53
I feel my manager provides encouragement and feedback about my work.	3.18	0.57
I have opportunities to practice skills and procedures more than once.	3.22	0.55
I feel supported by the nurses on my unit.	3.29	0.64
I feel staff is available to me during new situations and procedures.	3.35	0.51
I am supported by my family/friends.	3.41	0.50
My preceptor is helping me to develop confidence in my practice.	3.43	0.56
There are positive role models for me to observe on my unit.	3.44	0.55
I feel my preceptor provides encouragement and feedback about my work.	3.45	0.60

Job Satisfaction:

New nurses were asked to rate their job satisfaction utilizing alive point Likert scale ranging from 1 (very dissatisfied) to 5 (very satisfied). Job satisfaction items were related to benefits (3.84±0.78), encourage and feedback (3.42±0.70). Salary was rated as the lowest satisfaction (2.70±1.03).Table 5 shows mean score and SD of new nurse satisfaction.

Table 4 Role Transition of the New Nurses (n=178)

	n	%
Transition Difficulties
· Role expectations	139	78.1
· Lack of confidence	115	64.6
· Workload	101	56.7
· Fears	68	38.2
· Orientation issues	26	14.6
Support and Integration
· Improved orientation	141	79.2
· Increased support	125	70.2
· Improved work environment	77	43.3
· Socialization	71	39.9
· Satisfying Work Environment
· Peer support	135	75.8
· Ongoing learning	104	58.4
· Patients and families	83	46.4
· Professional nursing role	78	43.8
· Positive work environment	74	41.6
· Dissatisfaction with WorkEnvironment
· Interpersonal relationships	100	56.2
· System	61	34.3
· Nursing work environment	57	32.0
· Orientation	16	9.0

Table 5 Job Satisfaction (n=178)

Variable	Min.	Max.	Mean	SD
Overall Job Satisfaction	1.78	5	3.27	5.82
Benefits package	2	5	3.84	0.78
Encouragement and feedback	1	5	3.42	0.70
Weekends off	1	5	3.35	0.82
Opportunity to work day shift	1	5	3.34	0.85
Hours worked	1	5	3.32	0.85
Career advancement	1	5	3.19	0.78
Amount of responsibility	1	5	3.15	0.92
Vacation	1	5	3.15	0.92
Salary	1	5	2.70	1.03

DISCUSSION:

This study was conducted to investigate new nurses’ experiences during their first year of practice. New nurses participating in the current study reported many transition into practice experiences previously documented in the literature.It is important to note that even after 1 year of practice, 51.7% of new nurses still uncomfortable to perform code/emergency response, ventilator care, EKG, and chest tube care. The results indicate the potential risk to patient safety without well-managed training. These findings give a strong rationale for a year-long nurse residency programs that provide support through the first year of practice.

One of the most intense patient care issues a nursecan be involved in is a code or emergency response situation. Responding to a code is not so much about performing a skill, but about thinking critically to improve a patient’s condition. This is not a situation that every nurse will participate in, but it is something that can be discussed and simulated to improve critical thinking. There is abundant evidence suggest that simulation-based orientation promote skill performance, self-confidence and satisfaction of new nurses about resuscitation(Marzouk 2015; Waterval et al. 2012; Weller et al. 2016; Bortolotto 2015; LaVelle and McLaughlin 2008; Zekonis and Gantt 2007). The reporting of this difficulty supports the use of simulation as an educational tool to increase new nurse’s critical thinking and confidence in resuscitation situation.

Feelings of low confidence and incompetence are normal occurrences for new nurses (Casey and Fink 2009; Klingbeil et al. 2016). The new nurse revealed moderate confidence in performing most aspects of their job. This study found that there was resolution of difficulty with organizing and prioritizing and communication during 12-month transition period. These study findings similar to those from other investigators (Goode et al. 2013; Klingbeil et al. 2016). Both of these situations put the new nurse in an uncomfortable, unfamiliar position. The new nurse may tend to shy away from these situations so it is the responsibility of the preceptor to encourage the nurse and build confidence.

During the transition phase from student to staff nurse, support is an essential need of the new nurse. The new nurse needs to feel a sense of support and integration on the unit. Key factors in the work environment that are important for the transition of new nurses exist at the individual, team and organizational levels(Pfaff et al. 2014). Communication and interpersonal relationship have been cited as a key success factor of new nurses (Blevins 2016). The new nurses in this study indicated that improving orientation and more support from the manager, educator, and preceptor would assist in their transition on the unit. Evidence suggest that it is the institutional responsibility to implement strategies to support new nurses learning environment such as clinical nurse educator, preceptor training program, or residency facilitator(Myrick et al. 2012; Windey et al. 2015; Fuller et al. 2013).For Thai context, improvement of orientation process considering concept of nurse residency program which provide strong preceptor ship would give a positive outcome to new nurses.

According to the results, new nurses were satisfied with the benefit package they received from the institution. Salary was rated as the lowest satisfied issue. Results of this study are different from Western countries. Literature from Western point out that salary is the most satisfaction variables of new nurses(Klingbeil et al. 2016). It is possible because of Thai nurse have lower salary than nurses in developed countries.

CONCLUSION:

Graduate nurses participating in the current study reported many transitions into practice experiences previously documented in the literature. New graduate transition requires consistent support and professional development during the first year of practice. Orientation process, therefore; is a key component to facilitate academic to practice transition. Thai tertiary hospitals should consider transition-to-practice or nurse residency program for new graduate nurses to improved integration in this transition process. Initiatives of systems that support for the graduate nurse during the first year of practice such as formal 1-year graduate nurse residency programs are suggested.

ACKNOWLEDGEMENT:

The authors acknowledge the Nursing Professional Development Center, Department of Nursing, and Human Resource Department of King Chulalongkorn Memorial Hospital for the supporting and facilitating in data collection process of the study.

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Received on 06.04.2017 Modified on 10.05.2017

Asian J. Nur. Edu. and Research.2017; 7(4): 461-465.

DOI:10.5958/2349-2996.2017.00090.8