Social Ecological Perspective Organization

Running head: NURSING
Nursing
Name of the student:
Name of the University:
Author’s note

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Introduction:
A new graduate nurse is an individual who has just completed their nursing training and
has less than six months experienced as a registered nurse. Each newly placed graduate nurse
need to go through the period of transition when they try to develop from a student nurse to a
professional nurse. Transition is a first 12 months after graduation, when a student nurse enters
into clinical practice (Duchscher & Windey, 2018). However, this process of changing from state
to another is associated with many adjustments and challenges for nurses. Nurses are
overwhelmed by a sudden change in responsibility, identity and roles and this period is
associated with increase in stress level and work distraction issue for nurses (Wong et al., 2018).
According to Helgesen (2017), there is a rise in incidence of stress in newly graduate nurse and
they are at high risk of leaving their place of work or employment because of work stressors and
inability to handle challenges during the transition period. Due to the shortage of nurse, there is
a need to reduce rate of turnover among this group of nurse during the transition period (Hussein
et al., 2017). However, job satisfaction and turnover rate can be reduced only when there is clear
understanding regarding the challenges faced by graduation during the transition period. A
comprehensive review of the literature may help to get in-depth knowledge about transition
issues and provide adequate support to graduate nurse. The key themes that will be explored
include workload, team communication, theory-practice gap and blame culture. Based on the
review of findings under this theme, several areas of improvement and clinical practice
implications have been suggested.
Background:

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Newly graduate nurse, who are in the transition period suffer from high stress and poor
motivation because of transition shock. Transition shock is a term to define the experience of
moving from the familiar role of a nursing student to the unfamiliar role of professional
registered nurse (Duchscher & Windey, 2018). It is the initial stage of the role adaptation
process, graduate nurse suffer from emotional as well as psychological burden because of the
inability to provide safe care and frequently experiencing feelings of not being able to cope with
workload burden. According to the Kramer’s explanation, new graduate nurse display
withdrawal from the shock by showing emotions such fatigue, withdrawal, rejection and illness
(Wakefield, 2018). Transition shock is not a recent phenomenon. The first incidence of
transition shock was identified in 1970 and issues related to transition persist till the present time
too with majority of nurse feeling unprepared for the demands of professional practice (Ankers,
Barton and Parry, 2018).
There are many factors that lead to such kind of transition shock for nursing students.
One of the explanations given by Murray, Sundin and Cope (2019) is the high rate of theory-
practice gap. Due to limited exposure to clinical settings and experience of handling real patients,
nurses are vulnerable to making errors and not identifying any clinical deterioration on time. Due
to lack of experience and too many tasks at hand, many graduate nurses fail to prioritize time
management and end up ignoring patient safety responsibility (Murray, Sundin &Cope, 2019).
Thus, it is crucial that active support and encouragement is given to nurse at this time so that
they learn to identify deterioration and manage their time. According to Azimian, Negarandeh
and Fakhr-Movahedi (2014), staff shortage is another area leading to nurse’s struggle during the
transition period. The study explored factors affecting coping with transition among nurse by
conducting a qualitative interview with nurses. The study revealed lack of preparation for

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transition as one of the major cause behind transition shock. Factors like staff training,
development, professional relationship, welfare services and perceived level of support strongly
contributed to staff shortage. Moreover, Charette, Goudreau and Bourbonnais (2019) explained
the role of both organization as well as personal factors in influencing transition to practice.
Organizational factors included stability, orientation, workload and safety culture in any
hospitals and personal factors included personality of individual graduate nurse and lack of
professional curiosity.
Nursing or health care organization have identified the transition related challenges for
graduate nurse and implemented many initiatives or professional support programs to enable
nurse to effectively address challenges in practice. Education directed at eliminating incivility
and bullying is some example of continuous efforts to create positive work environment for
nurses. Based on new graduate nurse’s complain on incivility, zero tolerance policy has also
been implemented in many organization to foster behaviour change and promote culture change
(Dwyer & Revell, 2016). The implementation of the orientation program is also a positive
element that can not only provide them with stability but also lead to reduced workload
perception and anxiety.
Search strategy:
To search for relevant research literature according to the research aim, the search was
initiated in CINAHL and PubMed databases. The keywords to be used during literature
searching were taken from the following research questions:
What are the factors that influence a new graduate nurse’s transition into professional practice?

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The keywords that were taken from the above research question included ‘new graduate nurse’,
‘transition’, ‘professional practice’ and ‘factor’. Apart from these primary keywords, other
search terms were used by using synonyms in place of the above keywords. Some alternative
search terms included ‘newly placed graduate nurse’, ‘transition challenges’, ‘factors influencing
transition’ and ‘professional practice. To increase the likelihood of getting most relevant research
papers, the primary search terms were combined with several Boolean operators too. For
example, the key terms were combined in the following ways:
 New graduate nurse OR newly placed graduate nurse
 transition challenges OR factors influencing transition
 New graduate nurse AND transition challenges
 Newly placed graduate nurse AND transition challenges
The utility of using ‘OR’ between search terms was that it helped in retrieved those papers
which has either of the keywords. Moreover, the utility of using ‘AND’ was that it favoured
retrieving only those papers which had both the keywords.
In addition to the above process of searching, inclusion criteria were also developed to guide
selected of papers for the review. The inclusion criteria for article selection were:
1) peer review journal articles published in English language
2) Articles published within the past 5 years
3) Studies with newly placed graduate nurse as the participants
4) Studies reporting about transition related challenges or factors influencing transition
Those articles were excluded which did not reported about transition issues or which had
experienced nurse or nursing students as research participants. The title and abstract of each

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paper were reviewed first. The final selection was done based on comparison with inclusion and
exclusion criteria. In addition, reference list of selected articles were also considered to find more
papers. Out of 125 articles, total 10 articles were found eligible for the review. Other papers were
excluded as they reported only about transition shock prevalence or patient safety issue, but gave
no idea about what factors influence new graduate nurse (NGN) transition into professional
practice. The comparison and contrast of the six included papers will be done in the next
paragraph. The common characteristics of all the included paper were that all the studies had
qualitative research design and the studies explored perception in the form of themes. The final
list of selected papers and the key themes has been attached in appendix as table of evidence.
Results:
Workload:
There were multiple studies which identified workload as one of the factor influence
transition to professional nursing practice (Wong et al., 2018; Hussein et al. 2017; Ebrahimi et
al., 2016 and Azimian, Negarandeh and Fakhr-Movahedi, 2014). Workload issue has been
identified as a dominant factor that influenced NGNs transition to professional practice. The
qualitative study by Wong et al. (2018) reported nurse’s experience of heavy workload and
challenges in prioritizing routine work in the first few months. The need to manage multiple
tasks at the same time, completing ward rounds and frequent monitoring of high risk drugs
increased stress level of NGN. Hussein et al. (2017) discovered demanding workload as a factor
that prevented novice nurses capacity to develop clinical competence. This situation exposes
them to many unexpected clinical situations such as Medical Emergency Team (MET) calls and
the need to manage aggressive patient. Due to heavy workload, many nurses had the perception

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that they were working outside their scope of practice. In addition, Ebrahimi et al. (2016)
claimed the role of increased workload in leading to imbalance in demands and resources. Staff
shortage was the reason for increased workload and staff shortage hindered graduate nurse
ability to access support programs too. Azimian, Negarandeh and Fakhr-Movahedi (2014)
introduced the factor of workload issue too. Thus, putting extra workload on graduate nurse
itself denotes why NGN also go through negative emotions and intention to leave the job during
the first year of practice.
Theory practice gap:
Wong et al. (2018) highlighted about theory practice gaps and its impact on transition for
NGNs. Based on the evaluation of nurse’s perception, it was found that lack of advanced
knowledge and skills was a major factor challenging participants. Due to lack of in-service
training in the transition period, many nurses expressed the concern that unfamiliarity with a
particular service greatly increased anxiety and stress level for them. Ebrahimi et al. (2016) argue
regarding the same factor by giving evidence for poor competency among new nurses. The rate
of frequent careless mistake was high and they often preferred trial and error method instead of
using clinical judgment while dealing with chronic patients. Other examples of incompetency
included lack of problem solving skills, poor delegation kills and poor time management skills.
Dwyer and Revell (2016) identified the role of organization in leading to theory practice gaps too
Blame/complaint culture
There were two papers (Wong et al., 2018; Ebrahimi et al., 2016) which identified lack of
safety culture or blame culture as a barrier to effective transition to practice. Majority of graduate
nurse in the study by Wong et al. (2018) identified blame culture in their workplace. This acted

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as a major barrier for nurse in asking their seniors for support. Feelings of poor self-confidence
and fear of being criticised was a major challenge that affected graduate nurse’s intention to take
help from their seniors. In contrast, Ebrahimi et al. (2016) reported about poor working culture
by reporting about cultural taboos and feelings of stability threat.
Communication with the team:
According to a qualitative exploration of graduate nurse experience, team work affected
new graduates confidence level in positive as well as negative manner. In this study, graduate
nurses reported that they would prefer being formally introduced to the staff members. This
would give positive vibes and the perception that they are important part of the multiprofessional
team (Hussein et al., 2017). Communication weakness between senior staffs and novice nurse
was reported by Ebrahimi et al. (2016) too. This study evaluated perspective from the point of
view of senior nurses. They reported that new nurses lacked skill in establishing good
communication with the doctors. They were found to have poor skills in answering phone calls,
expressing their needs and communicating with the supervisor. This form of poor
communications skills might be due to poor organizational culture or deficit in personal attitudes
too. Ankers, Barton and Parry (2018) introduced positive effects of team communication by
showing positive feelings among graduates who got support from their seniors. Azimian,
Negarandeh and Fakhr-Movahedi (2014) highlighted about professional accountability issues by
showing that nurses who were more accountable had better commitment towards self-learning
compared to other groups.
Discussion:

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The review of research papers gave rise to four themes on factors influencing transition
for NGN. These four themes were workload, blame culture, theory practice gap and
communication with the team. The most dominant finding was that workload was a major cause
behind distress and transition shock among graduate nurses and four studies revealed about this
issue. Wong et al. (2018) revealed that workload influenced clinical knowledge and skills as well
as working relationship with patients and staffs. Heavy workload was evidenced from ratio of
1:12 for nurse to patients. This is a serious challenge as they failed to communicate with patient
because of workload and even admitted missing their lunch. The above issue directly influences
patient outcome and nurse’s confidence level. Hussein et al. (2017) reported workload as a factor
that makes transition experience stressful and emotionally challenging for NGNs. Workload is an
issue that will affect patient satisfaction level and lead to suboptimal care. Hence, this finding
gives the implication to the human resource department to consider workload issue so that
healthy work environment for NGNs could be fostered and rate of absenteeism could be
decreased (Kaur & Gujral, 2017).
From the review of the theme related to blame/complaint culture, it can be said that
blame culture is an indication of organization deficit and lack of availability of proper support
culture for newly placed nurse. This can not only affect NGN’s intention to get support during
critical point of care, but also obstruct effective communication process. Wong et al. (2018) and
Ebrahimi et al. (2016) highlighted about the impact of complaints culture of NGN’s ability to
seek support from their seniors. This resulted in extra stress for nurse. The study by Okpala
(2018) has explained that blame culture is a negative element in the organization that not only
affects nurse’s ability to report about errors but also nursing turnover rates. There are two major
risk associated with blame. Firstly, it will decrease error reporting leading to high risk of adverse

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events. Secondly, blame game culture can psychologically affect NGN as this will lead to
psychological stress and poor self-esteem too. Brborović et al. (2019) affirms that culture of
blame is a burden on patient safety as significantly increased healthcare adverse event rates. The
key implication of this finding is that it suggests the need for hospital administrators to conduct
more meetings with graduate nurse and understand their concerns. This would lead to the
development of a positive culture of safety.
Other two themes included communication with the team and theory practice gap. From
the review of the articles by Hussein et al. (2017) and Ebrahimi et al. (2016), impact of poor
communication on NGN’s transition experiences were found. Lack of team support is an
indication that novice nurses have failed to receive professional development support. Personal
communication gaps such as relaxed communication and experience of bullying was found to
disrupt effective communication with the team. In addition, lack of theory practice gap was
found to be major reason behind transition. This is consistent with the findings by Woo and
Newman (2020) which reported about use of harsh tone of communication and its emotional
impact on novice nurses. The theory practice gap gives implication for revising the nursing
curriculum too so that health industries could meet clinical demand and enhance core skill
proficiencies of NGNs. Moreover, there is a need for active implementation of orientation
programs too.
Conclusion:
To summarize, the literature review on factors influencing transition for NGNs defined
workload, communication with the team, theory practice gap and blame culture as the factors
leading to stress and challenges during the transition period. The issue of workload was the most

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commonly reported findings among participants. It suggest the need for recruitment staffs and
health leader to identify ways to maintain appropriate staff ratio and skill mix to better support
NGNs and decrease imbalance between resource and demand. The issue of theory practice gap
and communication issues should be looked at seriously by the health care administrator. It gives
the implication to improve existing simulation training and implement a training program that
exposed NGNs to all those activities that are part of daily ward operations.
References:

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Ankers, M. D., Barton, C. A., & Parry, Y. K. (2018). A phenomenological exploration of
graduate nurse transition to professional practice within a transition to practice
program. Collegian, 25(3), 319-325. DOI: https://doi.org/10.1016/j.colegn.2017.09.002
Azimian, J., Negarandeh, R., & Fakhr-Movahedi, A. (2014). Factors affecting nurses' coping
with transition: an exploratory qualitative study. Global journal of health science, 6(6),
88–95. https://doi.org/10.5539/gjhs.v6n6p88
Duchscher, J. B., & Windey, M. (2018). Stages of transition and transition shock. Journal for
nurses in professional development, 34(4), 228-232. DOI:
10.1097/NND.0000000000000461
Brborović, O., Brborović, H., Nola, I. A., & Milošević, M. (2019). Culture of Blame-An
Ongoing Burden for Doctors and Patient Safety. International journal of environmental
research and public health, 16(23), 4826. https://doi.org/10.3390/ijerph16234826
Charette, M., Goudreau, J., & Bourbonnais, A. (2019). Factors influencing the practice of new
graduate nurses: A focused ethnography of acute care settings. Journal of clinical
nursing, 28(19-20), 3618-3631. DOI: 10.1111/jocn.14959
Dwyer, P. A., & Revell, S. M. H. (2016). Multilevel influences on new graduate nurse transition:
A literature review. Journal for Nurses in Professional Development, 32(3), 112-121.
DOI: 10.1097/NND.0000000000000265
Ebrahimi, H., Hassankhani, H., Crowley, M., Negarandeh, R., Sadeghian, E., & Azizi, A. (2016).
Vulnerability of Newly Graduated Nurses in Clinical Setting: A Qualitative
Study. International Journal of Medical Research & Health Sciences, 5(9), 68-77.

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https://www.ijmrhs.com/medical-research/vulnerability-of-newly-graduated-nurses-in-
clinical-setting-a-qualitative-study.pdf
Helgesen, K. (2017). Stress in New Graduate Nurses: Can They Sweat It? A Correlational Study
of Exercise and Stress in New Graduate Nurses. DOI: https://doi.org/10.31979/etd.qy9r-
fed
Hussein, R., Everett, B., Ramjan, L. M., Hu, W., & Salamonson, Y. (2017). New graduate
nurses’ experiences in a clinical specialty: a follow up study of newcomer perceptions of
transitional support. BMC nursing, 16(1), 42. https://doi.org/10.1186/s12912-017-0236-0
Kaur, M. N., & Gujral, H. K. (2017). Work Load On Nurses And It’s Impact On Patientcare. J
Nurs Health Sci, 6, 22-26. DOI: 10.9790/1959-0605052226
Murray, M., Sundin, D., & Cope, V. (2019). New graduate nurses’ understanding and attitudes
about patient safety upon transition to practice. Journal of clinical nursing, 28(13-14),
2543-2552. DOI: 10.1111/jocn.14839
Okpala, P. (2018). Nurses’ perspectives on the impact of management approaches on the blame
culture in health-care organizations. International Journal of Healthcare Management, 1-
7. https://doi.org/10.1080/20479700.2018.1492771
Wakefield, E. (2018). Is your graduate nurse suffering from transition shock?. Journal of
Perioperative Nursing, 31(1), 47. https://doi.org/10.26550/2209-1092.1024
Wong, S. W. J., Che, W. S. W., Cheng, M. T. C., Cheung, C. K., Cheung, T. Y. J., Lee, K. Y., ...
& Yip, S. L. (2018). Challenges of fresh nursing graduates during their transition
period. J Nurs Educ Pract, 8(6), 30. DOI: https://doi.org/10.5430/jnep.v8n6p30

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Woo, M. W. J., & Newman, S. A. (2020). The experience of transition from nursing students to
newly graduated registered nurses in Singapore. International Journal of Nursing
Sciences, 7(1), 81-90.

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Appendix
Table of evidence:
Author,
year &
country
Methodology,
study design
and level of
evidence
Study aim Participant
s
Intervention Outcome
measures
Findings
Azimian,
Negarande
h & Fakhr-
Movahedi
(2014)
Country:
Iran
Level of
evidence: Level
VI
Exploratory
qualitative study
design using
semi-structured
interviews
To explore
factors
affecting
nurses’
coping with
transitions.
Sixteen
nurses
working in
four
hospital in
Iran
Transition
period
Factors
affecting
transition
Six major
themes in the
study included:
Heavy
workload
(because of
staff shortage)
as a barrier to
coping
Professional
commitment
motivate nurses
to gain more
knowledge
Wong et
al. (2018)
Hong
Kong
Level VI
Qualitative study
using interview
method
To provide
insight into
challenges of
transition
Eight
nursing
graduates
Understandin
g the
phenomenon
of transition
Impact of
transition
Workload, lack
of knowledge,
communication
, expectation,
change of role,

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working
atmosphere,
support and a
blame/complai
nt culture
identified as
major
challenges
Ebrahimi
et al.
(2016)
Iran
Level VI
Qualitative study
using
conventional
content analysis
To gain an
understandin
g of the
problems
and
difficulties
facing new
graduate
nurses in the
transition to
the clinical
setting
18
experienced
nurses
Vulnerability
of new
graduates
Challenge
s in
transition
Lack of
sufficient
knowledge
Communicate
weakness
Shortage of
manpower
Feel of stability
threat
Lack of
adequate
training
programs
Hussein et
al. (2017)
Australia
Level VI
Mixed method
design
To examine
change in
new graduate
nurses’
perceptions
New
graduate
nurse
Open ended
question on
transition
program
Analysis
of
emergent
themes
orientation and
Transitional
Support
Program as a
foundation for

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over the 12-
month
Transitional
Support
Program
success
developing
clinical
competence
Ankers,
Barton and
Parry
(2018)
Australia
Qualitative
research using
phenomenologic
al observation
To explore
the
experiences
of graduate
nurses
enrolled in a
transition
program
Graduate
nurse
Phenomenon
of transition
Thematic
analysis of
interviews
Time of many
new demands
Negative
emotions
Positive
feelings in care
of patient
Dwyer, P.
A., &
Revell, S.
M. H.
(2016).
Literature review To identify
factors that
influence
new graduate
nurse
transition
Graduate
nurse
Transition
experience
Analysis
using
social
ecological
perspectiv
e
Organization
factors like
workload and
poor safety
culture
Interpersonal
factors like
poor
communication

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