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International Journal of Nursing Studies 44 (2007) 12311237

The transitional journey through the graduate year:


A focus group study
Jennifer M. Newton

, Lisa McKenna
School of Nursing and Midwifery, Monash University, Peninsula Campus, Australia
Received 21 March 2006; received in revised form 19 May 2006; accepted 31 May 2006
Abstract
Background: Becoming a new graduate nurse is both a complex and stressful transition. Graduates must socialise into
the context of nursing practice, become accountable for patient care and ward activities, interact with other health
professionals and develop their own clinical expertise. In Australia, many hospitals provide Graduate Year
Programmes to assist new graduates to assimilate into their new roles and environments.
Aims: This paper describes a study that explored how graduate nurses develop their knowledge and skills during their
graduate programmes, as well as identies factors assisting or hindering knowledge and skill acquisition.
Methods: Employing a qualitative approach, this study used a series of focus groups and anecdotes to collect data from
25 participants recruited from four different hospitals in Victoria, Australia. Focus groups were conducted between 4
and 6 months, 11 and 12 months into, and 46 following completion of the graduate programme. Interview transcripts
were analysed allowing feedback to be provided to participants.
Results: Six themes emerged from the focus groups analysis that described graduates knowledge and skill acquisition
and reected their development at the different stages. These were: gliding through during undergraduate studies,
surviving, beginning to understand, and sheltering under the umbrella in the rst interview, knowing how to, and
weve come a long way by the end of their programme.
Conclusions: The year following graduation is one of immense personal and professional development. Despite nurse
education being in tertiary settings for many years, preparation of undergraduate students still appears unable to reduce
reality shock and ease transition for graduates into their working lives.
r 2006 Elsevier Ltd. All rights reserved.
Keywords: Focus group; Graduate nurse; Knowledge development; Transition; Socialisation
What is already known about the topic?
New nursing graduates experience feelings of being
unprepared and stress on entering the nursing work-
force for the rst time.
Professional socialisation for new graduates involves
adjusting to new roles, increasing accountability for
patient care, coping with fears of making mistakes or
interacting with other health professionals.
Graduates move through phases, initially internalis-
ing, focusing on themselves, before being able to
work independently and focus on patient and ward
requirements.
What this paper adds
Undergraduate nursing students underestimate their
preparation for their impending roles as new
ARTICLE IN PRESS
www.elsevier.com/locate/ijnurstu
0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2006.05.017

Corresponding author. Tel.: +61 3 99044375;


fax: +61 3 99044655
E-mail addresses: jenny.newton@med.monash.edu.au
(J.M. Newton), lisa.mckenna@med.monash.edu.au
(L. McKenna).
graduates and this could hamper their transition into
the workplace.
Perceiving oneself as a graduate offers some security
throughout the transition buffering inadequate
knowledge or clinical skills until able to act
independently towards the end of the graduate year.
More collaborative work is needed to develop the
condence of nal-year undergraduate students and
reduce stresses and feelings of unpreparedness for
new registered nurses.
1. Introduction
Preparation to become a qualied registered nurse in
Australia entails completion of a 3-year degree course.
On completion of their courses, most graduates seek to
undertake a 12-month programme offered by health
agencies. These programmes generally allow rotations
through several different clinical areas. A number of
studies (Kelly, 1998; Thomka, 2001) have identied that
new graduates enter their graduate programme with a
sense of feeling unprepared for their roles as new nurses.
This sense of being unprepared begins in the under-
graduate students nal year (Newton, 1999). However,
it is not clear whether these feelings remain with new
nurses throughout their graduate programme. This
paper presents the emerging analysis of a qualitative
study that has followed four groups of graduate nurses
during the initial 1618 months of being registered
nurses and shares the development of their knowledge
and skills over this period.
2. Background
Newton (1999), in an examination of undergraduate
student nurses perceptions of their ways of knowing,
identied that student nurses felt unprepared in the area
of their knowledge and skills on undertaking a clinical
practicum. In particular, the third-year students who
were about to complete their 3-year degree programme
voiced concerns that they were about to become
registered nurses and perceived themselves as not being
prepared for this role. The dichotomy between tertiary
education and clinical experience that is the theory
practice divide is not a new phenomenon. The vagarious
experience offered within a universitys simulated
clinical laboratory, in the eyes of the student, does not
reect the reality of the clinical environment. The
laboratory does not reect the wide spectrum of
concentrated human emotions, physical conditions and
the challenges and conicts that confront nurses (New-
ton, 1999). A study conducted by Heslop et al. (2001)
found that nal-year students expressed feeling prepared
with regard to knowledge, clinical practice, skills, time
management and decision-making, but not prepared for
caring for a caseload of ve or six patients, caring for
patients with complex problems or communicating with
doctors.
The expanding body of literature on the graduate
nurse discusses the stress and anxiety that new graduates
experience in their transition from student to qualied
nurse (McKenna and Green, 2004; Thomka, 2001;
Gerrish, 2000; Kelly, 1998). Several factors have been
identied that contribute to the graduates degrees of
stress. Primarily, these centre around the increasing
accountability for patient and ward management
responsibilities (Gerrish, 2000; Oermann and Garvin,
2002), socialisation expectations of being a professional
nurse (Ellerton and Gregor, 2003; Winter-Collins and
McDaniel, 2000; Kelly, 1998), and lack of consistent
support in the clinical environment (Thomka, 2001).
3. Literature review
Clouder (2003, p. 215) argues that professional
socialisation exists as a powerful structural reality in
which newcomers are subjected to a process of being
moulded into good professionals, which is fundamen-
tally disempowering. Professional socialisation in nur-
sing involves not only developing necessary skills and
behaviours, but also learning the norms and values
associated with practice (Howkins and Ewens, 1999).
Melia (1984) described socialisation issues experienced
by nursing students being complex as they faced two sets
of expectations. She identied these as the professional,
problem-solving approach emanating from within the
university, and the practical, workload-inuenced ap-
proach encountered in the wards. Students coped with
the clinical situations by tting in and saw themselves
just passing through.
However, as students become graduate nurses, the
ability to just pass through is not possible. They must
socialise into clinical nursing practice and their new
professional roles. Adjusting to this has been described
as both presenting stress and challenge. Kramer (1974,
1976) described the concept of reality shock as new
graduates enter clinical nursing roles to nd themselves
underprepared for the roles they believed they
were prepared for. Anxiety, feelings of being over-
whelmed and apprehension commonly emerge (Oer-
mann and Garvin, 2002; Thomka, 2001) from studies
around these individuals. Such feelings are fuelled
through fears as interacting with doctors (Duchsher,
2001), making mistakes (Oermann and Garvin, 2002),
being accountable (Gerrish, 2000) and having to per-
form clinical skills for the rst time (McKenna and
Green, 2004).
Chang and Hancock (2003) suggest that graduates
experience role stress due to role ambiguity and role
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J.M. Newton, L. McKenna / International Journal of Nursing Studies 44 (2007) 12311237 1232
overload. Role ambiguity includes lack of role clarity
and understanding of expectations while role overload
encompasses having inadequate time to complete
required work. These authors found that in the rst
few months after graduation, lack of role clarity was an
issue for graduates, while role overload was a problem
later. Both factors were found to negatively inuence job
satisfaction in the rst few months. Duchsher (2001)
found that graduate nurses experienced disillusion-
ment, disappointment and detachment as they faced
the inconsistencies between classroom theory and
practice contexts. Compounding this is the need to
adjust from controlled academic environments to
clinical environments which are difcult to control and
hence offer great challenges (Papp et al., 2003).
Socialisation into graduate nursing roles has been
found to be developmental with a number of studies
exploring different stages of the graduate year. In their
study, McKenna and Green (2004) found that in the rst
6 months following registration, graduates focus on
themselves, including their clinical skills, coping with the
realities of practice and themselves as nurses. In the
second 6 months, they began to focus on the bigger
picture of patient care, relationships and their own
ongoing development. Similarly, at 3 months after
graduation, Ellerton and Gregor (2003) found that
graduates dened their work in terms of a set of
skills, and were overwhelmed by the volume of work
required of them. In her study, Duchsher (2001) found
that different developmental stages occurred over the
rst 6 months. In the rst couple of months, nurses
were found to be self-absorbed and dependent. From
months 2 to 3, they began to feel comfort with
their limitations, more self-aware and developing
trust. At 5 months, nurses had begun to work more
independently, using critical thinking and developing
professionally.
4. The study
4.1. Aim
This study sought to examine how graduate nurses
develop their knowledge and skills during their graduate
programme and immediately after; and to explore what
factors, if any, assist or hinder graduates knowledge
and skill acquisition.
4.2. Design
Following a qualitative paradigm, focus group inter-
views with graduate nurses across four healthcare
facilities were conducted at three intervals over 18
months. Focus groups due to their synergistic nature
often produce data that are seldom produced through
individual interviews and can result in powerful inter-
pretive insights and provide access to the social interac-
tional dynamics amongst specic groups of people
(Kamberelis and Dimitriadis, 2005). In the context of
this research project, it was felt that focus groups would
provide a useful platform to explore graduates develop-
ment of their knowledge and skills, and to decentre the
role of the researchers and encourage a natural talk
and social interaction amongst the groups (Kamberelis
and Dimitriadis, 2005). In addition, monthly anecdotes
(see Van Manen, 1999) were submitted by a small
group of participants to the chief investigator for a
period of 16 months. This paper reports predominantly
on the data and analysis of the focus groups during the
rst 12 months. The anecdotes, which were short stories
of an event from clinical practice, were reviewed to
explore whether they supported the themes emerging
from the focus groups. A further paper is being developed
which examines in more detail the analysis of these
anecdotes.
4.3. Ethical considerations
Ethical approval was given by Monash University
Standing Committee Ethics on Research in Humans.
Five health agencies who offered a graduate nurse
programme were approached in late 2002 to elicit their
interest in participating in the study. Four agencies
expressed interest and ethical approval was obtained
from the relevant committees and permission given by
Directors of Nursing of the participating hospitals. This
did take a period of over 6 months and at two of the
health agencies it delayed the commencement of the
study until the following year (2004) to coincide
with the start of agencies graduate programmes.
Graduate nurses at each hospital were informed of the
study by one of the researchers during the rst weeks of
their programme and invited to participate. Those
expressing an interest were given an explanatory
statement about the study. Signed informed consent
was obtained prior to commencement of the rst focus
group interview.
4.4. The participants
All of the focus group participants (n 25) were
undertaking a graduate nurse programme. They were
voluntarily recruited from four different hospitals.
Eight were from a regional hospital, 10 from a large
(41000 beds) public metropolitan hospital, 3 from a
500-bed public metropolitan hospital and 4 from an
acute care small medium-sized private, outer metropo-
litan hospital. Amongst the total group of participants,
there were four males and the overall age range
varied from 2145 years of age. None of the participants
had previously worked as a Division 2 (enrolled) nurse.
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J.M. Newton, L. McKenna / International Journal of Nursing Studies 44 (2007) 12311237 1233
The participants were graduates from several different
universities within the state of Victoria, and one from an
overseas institution. All participants were assigned
pseudonyms to protect their identities in reporting
ndings.
4.5. Data collection
Despite some concern on the effect that group
dynamics have on the analysis of data (Reed and
Payton, 1997), focus groups were chosen as the most
appropriate data collection method. Focus groups were
seen to encourage interaction amongst participants, and
enhance the richness of the data. The focus groups lasted
approximately 40 min and were moderated by the
researchers. There was no power differential though
some of the participants were known to the researchers
from their undergraduate studies; the majority of
participants came from a range of universities. The
focus group interviews took place in seminar rooms at
the four participating hospitals with graduates from
each particular hospital.
Anecdotes were utilised as a means for capturing
incidents that the participants chose to reect on in
relation to their knowledge and skills. These participants
were not engaged in the focus group interviews.
The rst audio-taped focus group interview was
conducted between 4 and 6 months into the participants
graduate programme; the second 1112 months into the
programme and the third 46 months after completion
of their graduate programme. Three key questions were
asked at each interview. The rst focus groups interview
questions sought to elicit the participants initial
perceptions of where they were at in relation to their
knowledge and skills acquisition. The key questions for
the second and third interviews were developed from
preliminary analysis of the rst and second interview
transcripts, respectively, and were structured to explore
further some of the issues raised in the previous
interview. Table 1 lists all the key focus group interview
questions. Final data for the third focus group was
collected in August 2005.
4.6. Analysis
The rst and second focus group interview transcripts
were analysed following the seven steps offered by
Colaizzi (1978). This method was deemed appropriate
for the study to extrapolate the participants experiences
as graduates and identify themes that described the
factors inuencing their knowledge and skill acquisition.
Six themes have been identied from the analysis of the
focus groups interviews undertaken during the graduate
programme and these are discussed below. This analysis
was presented back to the participants for validation in
accordance with Colaizzis process.
4.7. The ndings
4.7.1. Gliding through
This theme relates to the graduates perceptions of
being prepared, or in many situations, an element of
unpreparedness for their graduate year. There was a
sense of going through their degree course and not really
taking on board a lot of what was happening. Thus,
when they hit the graduate programme they did not
feel prepared. This is exemplied by the following
quotes, Now I understand that I was not very prepared,
I knew that I could probably get through the day. I could
get patients showered and meds given but if anything had
gone wrong I dont think that I was prepared for any little
hitch in my day [Olivia]
I look back at it now and wish that I had studied a
bit more at uni but its hard to reinforce itI wish I
had taken in a bit more[Louise]. Cathy clearly
articulated her sense of unpreparedness, Clinically I
dont think that I felt readyywhen youre out there
doing it with very sick patientsyvery hard to umy
be prepared for that.
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Table 1
Focus group key questions
First focus group On completing your degree how prepared did you feel for your graduate program?
What has assisted your learning since commencing the grad program?
Where do you see yourself as a registered nurse (RN) in relation to your knowledge and skills?
Second focus
group
From your experiences to date how would you describe good nursing care?
Over the graduate program have you been in a situation where you have felt challenged?
From when we met six months ago what are your perceptions of yourself as a RN?
Third focus group What do you perceive to have had the most inuential impact in the development of your knowledge and
skills as a RN?
Does one need to establish ones self as a RN before one can focus on the patient/family?
From when we met six months ago what are your perceptions of yourself as a RN?
J.M. Newton, L. McKenna / International Journal of Nursing Studies 44 (2007) 12311237 1234
The rst 6 months of undertaking a graduate
programme was perceived by the participants as the
most difcult and the next two themes highlight some of
their difculties.
4.7.2. Surviving
This theme centres on the realities of practice where
graduates are coming to terms with the realities of the
real world of nursing. There is quite a focus on
themselves as individuals and, trying to manage their
time and get the tasks done, as illustrated by these
participants comments. Initially I was just capable of
my doing my task knowing what I had to get done and
getting help if anything else went wrongy [Nance] and
[Louise] Overwhelmed in that time management as-
pectyI did not feel condent in time management side of
ityI was running about a bit like a chook without a head
for a while.
I think that as a student it is assumed that you are so
used to working one to one and getting lots of
support and now being that you are out there on
your ownyand what is the drip-rate? [Dee].
A key component emerging from the analysis that
inuenced the participants acquisition of their knowl-
edge was learning the social hierarchy that prevails and
this is identied in the next theme.
4.7.3. Beginning to understand
This theme relates to the graduate learning to know
where they t in, knowing who to ask, when not to ask.
It is about learning to establish their place in the nursing
culture and organisation. Heather expressed her concern
that the type of rotation [ward] inuences ones
experience, it depends on what ward you go toyI think
that its a big thing trying to t into a group who do not
know you and that was really hardy . Jane discussed
the power dynamic, Its daunting each time you change
your rotation you have to get to know everybody again.
But once you nally work out the powery at the end of
four months nally get comfortable and then be moved
again, and as Gabby noted in changing wards and
being confronted with a preceptor she did not nd very
approachable, I have to kind of nd the people that I
know that I can go to. Ingrid voiced the dilemma
experienced by many of the participants, it is hard when
you change wards and you do not know any of the staff
and you do not know who you can approach and who you
cannot andyall the staff dynamicsyand [it] takes you
easily a month to feel comfortable with all that. Some-
times I can be a bit outspoken and then it comes back on
me a little and I sort of try and bite my tongue a little bit
some time. So it is hard sometimes when you are trying to
nd that bit of balance.
Despite these apparent difculties the graduates
faced in learning the organisational culture and
establishing themselves within the hierarchy, towards
the end of the rst 6 months, there appeared to be an
element of condence emerging. Though being a
graduate is also a safety mechanism as identied in
the theme below.
4.7.4. Sheltering under the umbrella
There is a sense of gaining condence halfway
through the graduate programme though the pro-
gramme acts as an umbrella in times of uncertainty for
the graduate to retreat under.
and there is then knowing when to call for the doctor
and I know initially to start with I would ask a nurse
rst and now Im more condent for helpyI wont
go and ask the nurse Ill check with the doctor
[Louise]. I think as the Grad you are the one who
needs help, youre the one who actually wants the
help after the questions, whereas the other more
experienced staff dont need that helpysome dene
me as a Grad, [Ann]; She [referring to graduate
coordinator] always comes when I call, I can ask her
anything it can be as dumb as and she just responds
[Cassie].
4.7.5. Knowing how to
By 1112 months into their graduate programme, the
expectations of the participants were that they should
know how to manage an emergency situation. As they
had been taught the theory in their preparatory courses,
there was a strong sense that they should be able to
handle the situation when they were confronted with it,
as illustrated below.
A baby aspirated while I was feeding and shock set
in, for she went blue and the rst thing that I thought
of was to get oxygen and then it was like what
now?y I felt that I cant just let someone else take
over so I felt challengedyI had to try and do what I
was supposed to have learnt to do so I didy,
[Marg].
This was just one of several similar experiences
recounted by the graduates when they were put into a
position that challenged their application of knowledge
and skills. In developing their knowledge and skills over
the graduate programme, the participants acknowledged
that they had gained signicantly though as the last
theme highlights there was still room for learning.
4.7.6. Weve come a long way
Towards the end of their graduate programme, the
graduates had begun to acknowledge that they actually
knew how to nurse, though there was still more to learn
and this is captured in the participants comments,
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J.M. Newton, L. McKenna / International Journal of Nursing Studies 44 (2007) 12311237 1235
I think now that I can justify what Im doing Im not just
doing something, [Casey]. And as Beth stated, there is
still so much more to learn and Edith commented, You
still recognise that theres still so much more to learn that
you just think of what you have learned already. Its
amazing. Whilst Louise acknowledged that she had
gained much in her learning she recognised that this was
part of a continuing process: heaps more condence and
have got more knowledge on board, still have more to
learn [Louise].
5. Discussion
Several key issues have emerged from this analysis
that present challenges to both educators and clinicians
in how to address them. From the experiences of these
graduate nurses, the reality shock, that Kramer (1976)
identied, still prevails nearly 40 years on. Pre-registra-
tion nursing education in Australia has been in the
tertiary sector for over two decades. Despite this, it
would seem that as a professional body, nursing has still
not been able to address this highly confronting issue for
new nurses.
The sense of being unprepared at the completion of
their undergraduate studies to face the responsibilities
and challenges of being a registered nurse, as experi-
enced by this group of graduate nurses, begs the
question for educators what can be done to address
this. Signicant of this nding is that it was just
not experienced by one group of graduate nurses
from a particular tertiary institution. The partici-
pants in this study were from several universities; both
city and rural campuses, within the state of Victoria, and
one participant had graduated from an overseas
university.
The clinical learning environment, which has been
identied as having a direct impact on undergraduate
student nurses (Dunn and Hansford, 1997; Chun-Heung
and French, 1997; Pearcy and Elliot, 2004), would
appear to signicantly impact on the graduate as well.
Clare and van Loon (2003, p. 28) report that 48% of
respondents in their study, examining the transition
from student to registered nurse, described unprofes-
sional behaviour such as horizontal violence, bullying,
bitchiness that they had either witnessed or experienced.
Clearly, exposure to this type of behaviour does not lend
itself to a conducive learning environment. Participants
expressed that their preceptor was pivotal to their sense
of well-being and feeling supported in each clinical
rotation. Critical to the participants assimilation into
the clinical environment was learning the ward culture.
As the analysis highlights, beginning to understand
impacts on the development of the graduates knowl-
edge and skills while they take time to learn the rules
and prevalent hierarchy. The graduate year is an
extensive year of development for the newly registered
nurse. Thus, it raises the question of whether graduates
need the repeated distraction as they rotate through
different clinical units of having to establish where they
t in. Whilst the philosophy behind multiple rotations is
to provide an exposure to a wide range of clinical
settings, it would appear that it could be detrimental to
their learning. Clare and van Loon (2003) note that the
length of rotations is a contentious issue, with graduates
disliking the insecurity of leaving a unit when they are
just beginning to feel they can contribute. It would seem
that health agencies need to consider only offering one
clinical placement which would enable the graduate to
develop and consolidate their knowledge and skills thus
creating a sense of being a valued member of the
healthcare team. A small minority of health agencies in
Australia have recently reduced their graduates rota-
tions to two. Further research may be warranted to
compare these graduates experiences, in relation to the
ndings of this study, in the area of workplace
socialisation.
The transition from the tertiary environment to the
real world of nursing remains a problematic issue for
educators. Despite many tertiary institutions offering
transition units at undergraduate level, anecdotal
evidence afrms the graduates comments, I wish I
had studied a bit more. It would seem that for many
students they glide through their undergraduate degree
perhaps knowing that theyll be supported under the
umbrella of a graduate year thus perpetuating a sense of
dependence, rather than independent, autonomous
practitioners. It may be argued that educators have a
responsibility to provide opportunities that encourage
active engagement of students within the simulated
clinical laboratories, and promote a sense of indepen-
dence and preparedness for the reality of the workforce.
Certainly, the ndings of this study highlight that
graduates experience an immense adjustment from the
transition of student to registered nurse. They are
learning how to manage their time, to meet the
challenges of connecting theory with practice and
signicantly grapple with the occupational socialisation
into a profession.
Forty years on from Kramer, the reality for these
graduate nurses entering the workplace still has an
element of being underprepared for their professional
roles. In the provision of undergraduate nurse educa-
tion, education providers need to continue to explore
pedagogical approaches that will ease the transition of
student to graduate. With current nursing shortages,
under preparation of students for the reality of nursing
practice needs to be addressed. Further research into
more appropriate education and clinical practice strate-
gies for preparing work-ready graduates is required.
Similar studies within other settings would allow some
comparison to be undertaken.
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6. Limitations
It is acknowledged that these ndings are limited to a
selection of graduate nurses across four health agencies
within one state of Australia, so may not be reective of
graduates experiences elsewhere. Four of the participants
were known to the researchers though this did not appear
to impact on the group dynamics that they were in.
7. Conclusion
Several studies have highlighted the difcult nature of
the transition from student to registered nurse. This
study has suggested that this may be contributed to
during the undergraduate nursing courses and by the
students, themselves. Graduate nurse programmes offer
new graduates an umbrella under which to shelter;
however, work needs to occur within preparatory
nursing courses to minimise the burden experienced by
these graduate nurses.
Acknowledgement
This study was funded by the Monash University,
Small Grants Scheme. We are indebted to the partici-
pants who supported the project throughout its dura-
tion, and to the graduate coordinators who were pivotal
in assisting the researchers in gaining access to the
graduates and encouraging participation in the project.
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