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Draper, Janet; Sparrow, Shelagh and Gallagher, Donna
(2009).
Abstract
This paper presents the findings of a Centre for Excellence in Teaching and Learning-funded project exploring the experience of student nurses making the transition from student to qualified nurse.
The transition from student to staff nurse ‘is a common rite of passage that marks the end of initial educational preparation in the discipline and the beginning of the professional journey as a nurse’ (Nash et al, 2009: 49). However, the extent to which newly qualified staff nurses are able to competently practise at the point of registration has been questioned across a range of policy, professional and academic forums. At a policy level, recent reviews in England of both pre- and post-registration nursing (DH, 2007; NMC, 2007) have highlighted concerns regarding fitness to practise at the point of registration. It has been suggested that nurses lack clinical skills and that pre-registration education has ill-prepared them for their staff nurse role. Indeed Clark and Holmes (2006, p.1217) write that ‘it cannot be assumed that the newly qualified are competent to practice independently and without supervision at the time of registration’. Furthermore, previous national and international research in this area indicates that students find this transition stressful and that there is a lack of support in practice to support this transition (for example, Dury at al, 2008; Brennan and McSherry, 2007; Mooney, 2007; O’Shea, 2007; Gould et al, 2006; Ross and Clifford, 2002; Gerrish, 2000; Maben, 1998). These concerns have led to proposals for a mandatory preceptorship period for the first year post-qualification (NMC, 2007).
The experience of transition
Much of the literature describes the transition as a stressful and traumatic process (Brennan and McSherry, 2007), what Kramer (1974) called ‘the reality shock’. Whitehead’s (2001) participants, for example, likened it to ‘flying without a parachute’. The increase in responsibility and accountability, the fear of failure and litigation, a perceived lack of clinical skills and unrealistic expectations of other staff have been reported as the greatest sources of stress (O’Shea and Kelly, 2007; Whitehead, 2001; Biley and Smith, 1998; Kelly, 1998). Students making this transition have also articulated a significant difference between the real world of practice and the ideal world taught at university (Whitehead, 2001; Kelly, 1998).
Pre-registration education
Much of the research comments on the extent to which pre-registration education prepares students for both this real world of practice and the transition process itself. In her formative work on professional socialisation, Melia (1987) spoke of the ‘fracturing’ of the academic and practice components of education. Similarly, Ross and Clifford (2002, p.546) described students being ‘caught between the socialising forces of academia and the day-to-day reality of nursing’ and, as noted above, deficits in managerial, organizational and clinical skills are commonly reported (O’Shea and Kelly, 2007). Clark and Holmes (2006, p.1211) forcefully conclude that pre-registration education has not equipped students ‘with the knowledge, skills or confidence necessary for independent practice’.
Historical changes in the organisation of pre-registration education in the UK may have contributed to this situation. Prior to the transfer of nurse education to the Higher Education (HE) sector in the mid-90’s, nursing’s ‘apprenticeship-based’ training model was primarily focused on the acquisition of practical and clinical skills. However, it was subsequently criticised for its lack of a strong theoretical foundation. Following the move to HE and initial ambiguity concerning clear lines of responsibility and accountability for mentoring and teaching in practice, criticisms have been made of a lack of clinical focus. The recent modernization agendas (DH, 2007; NMC, 2007) seek to rectify this imbalance.
Practice support
Good curricula are contingent on high quality support and effective practice learning environments. Much of the existing literature describes a lack of support during the ‘nitty gritty’ coal-face transition to the role of staff nurse. Because the clinical environment is so pressurized there is often limited resource to support colleagues as they make this transition. Preceptorship and induction are reported as being patchy at best and non-existent at worst. Hardyman and Hickey (2001) in their study investigating newly qualified nurse’s expectations of preceptorship, found that preceptorship ‘smoothed’ the transition from student to staff nurse. Preceptors’ support of clinical skills development was cited by preceptees as the most important aspect of their role.
In light of the investment made in pre-registration education, the recognition that staff are our most precious resource and that lack of support can contribute to attrition from the profession (Hardyman and Hickey, 2001), understanding the experience of this transition and the factors that support it is an important imperative.
Objectives
The purpose of this project was to explore the experience of student nurses negotiating the transition from student to qualified nurse. The Open University (OU) pre-registration nursing programme is a unique, part-time, work-based distance learning programme designed for Health Care Assistants (HCAs) employed and sponsored by their organisation. Students remain employed as HCAs over the duration of the 4 year programme combining this with the role of student nurse. As students already have significant experience of working in health care before embarking on pre-registration education, we were particularly interested to explore the extent to which this prior experience influenced their experiences of the transition to staff nurse.
The objectives of the project were to:
• Examine students’ experiences of the first 3-6 months post-qualification, as they adapted to the demands of qualified practice
• Theoretically analyse these transition experiences using Van Gennep’s (1909 [1960]) theory of transition (see below)
• In light of these transition experiences, explore students’ perceptions of the extent to which the programme of study prepared them to practise as qualified nurses
• Feedback the accounts of these students into end-of-programme supplementary course materials for the benefit of future students
• Examine the potential of developing a web-based resource to support student nurses at the point of qualification as they make their transition to qualified practitioner.
Sample
The UK-wide sample was drawn from completing students of the OU part-time, distance learning, pre-registration nursing programme. Students completing within the last 6 months were invited to participate in the study and 15 from across the nations and regions eventually participated in the study.
Data collection
Working within an interpretive paradigm and informed by a critical review of the relevant literature, the project used telephone interviews to explore those factors that at an individual and organisational level influenced students’ experience of transition. Telephone interviews were used in preference to individual face-to-face interviews in order to accommodate the dispersed geographical spread of the students across the regions and countries of the UK. Interviews were recorded using digital recording equipment.
Ethical considerations
National Research Ethics Committee approval was granted and the ethical principles of confidentiality, anonymity and informed consent upheld throughout the study. Students were assured (at invitation to participate and again at interview) that confidentiality would be maintained at all times throughout the project. Anonymity was protected by using pseudonyms for both students and their host organisations. Following a letter to all completing students, interested participants were invited to respond by returning a statement of informed consent in a stamped-addressed envelope. On receipt of this, the project investigators contacted the participant to arrange a convenient time for the telephone interview. Participants were reassured that they could withdraw from the project at any stage.
Data analysis
Following verbatim transcription, data were analysed using conventional approaches to qualitative data analysis, supported by use of NVivo. Recurring themes were identified and exposed to theoretical analysis using Van Gennep’s theory of transition and the relevant nurse education literature.
Whilst others have also used theoretical concepts of transition (for example, Drury et al, 2008; Begley, 2007; Gould et al, 2006; Brennan and McSherry, 2001; Glen and Waddington, 1998), few have done so using it in its ritual sense. Those that have (for example, Nash et al, 2009 and Barton, 2007) suggest it has universal application.
Van Gennep worked as an anthropologist in France in the late nineteenth and early twentieth centuries. From his observations of traditional societies, he proposed that individuals within a society move between fixed positions or events such as birth, childhood, marriage and death. Central to his analysis was not necessarily the nature of the position or status held by the person, but the passage or movement between positions.
In observing movement across these positions he suggested that a common pattern was discernible, which recurred irrespective of the event. He described this pattern in terms of three phases – separation, transition (or limen) and incorporation – which he called 'rites de passage'. Separation was characterised by removal of the individual from his or her ‘normal’ social life. The transition or liminal phase was a stage between social statuses, where the individual no longer belonged to the previous status but had not yet completed the passage to the next. This transitional or liminal phase, in which the individual occupies a non-status, a kind of no-man’s land, was regarded by Van Gennep as potentially threatening and harmful. Rituals associated with the individual assuming the new status marked the phase of incorporation. Through the phases of rites of passage therefore, the individual enters as one kind of person and emerges as another.
Despite its early anthropological roots, Van Gennep’s theory still has contemporary application as a framework for understanding the ways in which transitions (of whatever nature) are both made and marked. The project used these 3 stages of transition to help understand the ways in which student nurses make and mark their transition from student to staff nurse.
Findings
This core paper presents the findings of the project, illustrating conceptual analysis with reference to excerpts from the data. It describes how students began to prepare for ‘separation’ from their student role, their powerful accounts of the betwixt and between ‘liminal’ phase and their experiences of ‘incorporation’ into their new status. In the current policy climate in England, with its strong focus on the review of pre-registration education, the paper makes some tentative recommendations for consideration.
References
Barton, T. D. (2007) Student nurse practitioners – a rite of passage? The universality of Van Gennep’s model of social transition, Nurse Education in Practice, 7, pp.338-347.
Begley, T. (2007) Who am I now? The experience of being a post-registration children’s student nurse in the first clinical placement, Nurse Education Today, 27, pp.375-381.
Biley, F. C. and Smith, K. L. (1998) ‘The buck stops here’: accepting responsibility for learning and actions after graduation from a problem-based learning nursing education curriculum, Journal of Advanced Nursing, 27, pp.1021-1029.
Brennan, G. and McSherry, R. (2007) Exploring the transition and professional socialisation from health care assistant to student nurse, Nurse Education in Practice, 7, pp.206-214.
Clark, T. and Holmes, S. (2007) Fit for practice? An exploration of the development of newly qualified nurses using focus groups, International Journal of Nursing Studies, 44, pp.1210-1220.
DH (2007) Towards a Framework for Post Registration Nursing Careers – Consultation document, Department of Health, London.
Drury, V., Francis, K. and Chapman, Y. (2008) Letting go and moving on: A grounded theory analysis of disengaging from university and becoming a registered nurse, Nurse Education Today, 28, pp.783-789.
Gerrish, K. (2000) Still fumbling along? A comparative study of the newly qualified nurse’s perception of the transition from student to qualified nurse, Journal of Advanced Nursing, 32(1), pp. 473-480.
Glen, S. and Waddington, K. (1998) Role transition from staff nurse to clinical nurse specialist: a case study, Journal of Advanced Nursing, 7, pp.293-290.
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Whitehead, J. (2001) Newly qualified staff nurses’ perceptions of the role transition, British Journal of Nursing, 10(5), pp.330-339.
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