Nursing

support that is provided during the transition from a student nurse to newly qualified nurse

Introduction

The support that is provided during the transition from a student nurse to newly qualified nurse (NQN) is fundamental for preparing and supporting an individual for their career in nursing. Furthermore, McCuskey (2013) and Marks-Maran et al., (2013) highlight that NQNs are the future of the nursing profession and should, therefore, be supported to develop, with clear investment in the early stage of their newly qualified career. They are a crucial lynchpin for the future of the NHS. According to Henderson and Eaton (2013), it is paramount that NQNs undergo a smooth transition to their career from a student nurse A contrary to this may consequently affect patient safety and the quality of care provided (Hollywood, 2011). Furthermore, with a rapidly ageing population bringing forth cases of increasing complexity, an NQN receiving robust support and guidance is likely to become a defining issue within the NHS over the next generation (Price, 2013, Hanson, 2014). It is paramount for NQNs to be supported through this transition to ensure consistent, high standards of care given to service users (NMC, 2015).

This independent project will review the literature that is available concerning the transition from student nurse to newly qualified nurse and the effectiveness of the support that is offered during this transition. A student nurse will undergo a transitional process to become a fully functioning NQN, and when doing so, they may face many challenges (Hughes and Fraser, 2011, Rush et al., 2014). With this in mind, this study will focus on exploring the effectiveness of the strategies and interventions that the National Health Service (NHS) uses to support the student nurses to become NQNs.

A student nurse is defined as an individual who is not a registered nurse (RN) but is undergoing the process of educational preparation and clinical placements under supernumerary status to become an RN (Nursing and Midwifery Council, (NMC), 2015). Furthermore, according to the Royal College of Nursing (RCN, 2014), an RN is an individual who has passed all their assessments and examinations and is actively practising as a nurse in a clinical setting.

Lewis and McGowan (2014), highlight that the process by which nursing professionals transform from one classification to the other is often significant in defining a nurse’s career This transformation is also reported to be intensely demanding (Mooney, 2007). Furthermore, the NQNs, now have the new demand of being accountable to the NMC and the responsibility of having their patients that further adds pressure to the above-stated professional transition (RCN, 2017).

In addition, Health Education England (2014) stresses that NQNs experience a high proportion of stress and exhaustion within the first and second year of their qualifying career. Consequently, NHS Improvement (2014) estimate that it costs the NHS, 400 million each year, due to work associated stress. Understanding this transition is crucial to the maintenance of the NHS, especially in an era of austerity cuts by the government who are also reliant on agency staff (Dean, 2015). In 2014, the RCN identified that the NHS in England spends 980 million each year alone on agency staff (Good Governance Institute, 2015). Additionally, as well as having on impact on the financial budget of the NHS, this also can have an impact on patient standards due to the of the lack of continuity of care (Good Governance Institute, 2015).

Rationale and Justification

In a period of unprecedented pressure upon the NHS regarding funding and staffing levels, Whitehead and Holmes (2011) estimate that over half of NQNs in the United Kingdom (UK) make up the nursing workforce. In light of the sheer volume of NQNs in the NHS, there is a clear need to study the effectiveness of the procedures, through which such a high percentage of nursing professionals are assisted to become experienced practitioners. Additionally, Gillen (2014), highlights the acute nursing shortage within the NHS. It was found that this intensifies the need further to study the robustness of the processes used not only to bridge the gap between student nurse and NQN classification but also to protect fragile staffing levels (Banks et al., 2010, Jamieson et al., 2012). According to Henderson and Eaton (2013), it is paramount that NQNs undergo a smooth transition in their career from a student nurse because if they do not, this may consequently affect patient safety and the quality of care provided (Hollywood, 2011). Furthermore, with a rapidly ageing population bringing forth cases of increasing complexity, an NQN receiving robust support and guidance is likely to become a defining issue within the NHS over the next generation (Price, 2013, Hanson, 2014). It is paramount for NQNs to be supported through this transition to ensure consistent, high standards of care given to service users (NMC, 2015). Moreover, this shows that this transition is, in fact, a challenging and stressful time for the NQNs (Hughes and Fraser, 2011). After all, if there were no problems when transitioning, there would be no need to provide support mechanisms (DOH, 2010). Furthermore, a study conducted by Smyth (2013) emphasised that one in four NQNs left the nursing profession within three years of qualifying due to “burn out’’, lack of support and increasing workload. Hence, it is important to find the cause lies behind the high attrition rate among the nursing professionals in the UK and its relation to the support provided by the NHS to the NQNs.

Aim

The purpose of this literature review is to analyse how effective the current support given to NQNs is and whether this equips and enables them to become skilled and safe practitioners. Furthermore, it is also reassuring for student nurses to know that there are supportive mechanisms in place to help for attaining a successful transition from a Newly qualified Nurse to a registered nurse. This process is crucial not only to individual nurses but the integrity of the NHS. Hence, the aim of this study also includes to explore the range to which the support system can support the NHS as well, for obtaining an efficient and satisfied pool of nursing professionals.

Literature search

The University of Wolverhampton portal access was used to identify relevant literature to assist this study, using the population, intervention, comparator, outcomes (PICO). According to Polit and Beck (2014), using databases is more reliable and trustworthy compared to using ‘the internet’ as the literature held on the databases is peer-reviewed, reliable and trustworthy articles. In addition to this, the literatures have been used for this studies as they are academic sources and research questions are directly related to the topic selected for this particular study. The researcher has found these article as the most credible as they were written and moderated by healthcare professionals with detailed knowledge of the health care sector, which increased the validity of the articles (Polit and Beck,2014). They also allowed the author to access a range of high-quality research papers and sources for the report.

The dates of publication were limited to between 2010 and 2017 for obtaining the most recent and thus relevant information in the modern context. These search limiters were used to narrow down the available literature and make it more specific to the research question (see Appendix 1 for extraction table). Moreover, to find articles relevant to the question, an advanced search was initiated which enabled other databases to be searched, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed and ProQuest and Medline. In which this facilitated the execution of a wider search.

Thematic analysis of research finding

A thematic approach has been used to structure the review of the literature. In light of the chosen research articles, three themes became apparent; these were as follows: Theme One: The fundamental weaknesses of the transition in becoming an NQN: lack of appropriate support. Theme Two: Existing strategies supporting the NQN in practice, and Theme Three: The overriding need for emotional resilience in NQNs.

A thematic approach has been used to structure the review of the literature in this study it provides an easy to follow format, provides a clear and logical approach to the analysis enabling core findings from these research papers to be presented. The research papers have also been critically appraised regarding their reliability and validity for their results to be used with credibility (Cronin et al., (2008).

Theme One: The weaknesses of support through transition

All findings of the research papers included in this review report that the most significant weakness is the lack of appropriate support is offered to nurses during their transition to becoming an NQN. Hollywood (2011), Jones et al., (2014), Lewis and McGowan (2014),Tracy and McGowan (2015) and Maxwell et al.,(2011), all conducted interviews with NQNs and their results emphasised how support is one of the most essential components of the transition between student nurse and qualified nurse.

As discussed by Rush et al. (2013) a strong and efficient preceptorship for the newly qualified nurses can benefit the NHS in fulfilling its major objective of providing the best care to the UK population. As opined by Missen, McKenna and Beauchamp (2014) efficient preceptorship among the NQNs can enhance the patient care and provide and efficient nurse base to the health care profession. However, as identified by Wolff, Pesut and Regan (2010) a weak support system for NQNs can low down the performance of the qualified nurses which can harm the confidence level of the professionals. Hence, from the above discussion, it can be mentioned that an efficient preceptorship is important for the NHS to increase satisfaction level among the nurses which can positively serve in reducing the absenteeism and increase the staff retention rate which is one of the major problems the NHS is facing.

However, Maxwell et al., (2011), conducted a qualitative study using in-depth individual interviews of NQNs working within the community and hospital settings. They found that some preceptorship models are poorly structured and disorganised which can also be interpreted as a lack of support and cause further difficulties in the transition of an NQN. Similarly, Lewis and McGowan (2014), who also used a qualitative approach to obtain data, by doing semi-structured, one-to-one interviews on eight NQNs, found that there were discrepancies in preceptorship programs and concluded that more rigorous and continuous support needs to be given to NQNs. In which it is further supported by Hollywood (2011).

On the other hand, Hollywood (2011) explored the transition of NQNs using one-to-one interviews and found that when preceptorship is introduced, it provides support and positively enhances the experience for NQNS and hence, it has identified that the NQNs are supporting and expecting systematic support program for smooth and effective transition experience. However, as the research has interviewed a small number of respondents the result cannot be generalised. Hence, it can be suggested that further researches can be conducted by exploiting this limitation of the research for exploring the attitude of the NQNs to the support programs. As discussed by Procter et al. (2011) the nurse's attitude is also important in identifying the effectiveness of the NHS support services to the NQNs. However, Xu and He (2012) has identified that nurses expect such services for obtaining confidence and autonomy in their career.

In addition to this, as mentioned in the research of Rush et al. (2014) one of the major weaknesses of this preceptory program for the nurses is the presence of bullying and horizontal violence to the less experienced nurses in the wards. As opined by Frederick (2014) this is instrumental in undermining the confidence of the newly qualified nurses. As mentioned by Berry et al. (2012) such workplace bullying to the qualified nurses is creating an unpleasant experience for the nurses. Hence, it can be speculated that such a negative experience in the transition period is likely to encourage them in discontinuing their career as professional nurses and the NHS is facing high turnover rate. Moreover, it can also be stated that this particular weakness in the support system is debarring the investment of NHS on this system from being fruitful. However, this article has not specified any structured process for eliminating this issue of bullying from the preceptory program. Further researchers can identify it as a scope of exploring the processes for advancing and improving the preceptory procedure for the NQNs.

On the other hand, the research of Missen, McKenna and Beauchamp (2014) have identified an unrealistic high expectation as a major weakness of this preceptory program. The research has identified that the newly qualified nurses are often sent to the hospitals or clinics in their transition period where the management needs highly skilled and experienced professionals to serve. This situation creates a sense of dissatisfaction and lack of confidence among the nurses. However, it can be identified as a lack of systematic planning and management orf the program which is one of the major weaknesses.

The research result of Jones et al., (2014), identified that there was more satisfaction for new NQN if preceptorship was organised and persisted for four or more months. This was further supported by Tracy and McGowan (2014), who used recorded interviews of eight preceptor participants who stated that the transition of NQNs is challenging, but a longer preceptorship allows NQNs to become safe, and confident nurses. However, it could be suggested that this finding lacks validity as the result derived from the perception of the preceptors rather than the perceptees.

Moreover, Jamieson et al., (2012) used evaluations to conduct further research and assess the use of ‘Flying start NHS’, which was introduced in 2006 to support NQNs in Scotland. ‘Flying start’ is an addition to preceptorship which allows NQNs to use online resources that support individuals to progress and develop up to a year of transition.

Theme two: Existing strategies supporting NQNs in practice

There is, however, a wide range of different strategies currently in place across the NHS to support NQNs during the transition period of the NQNs. These various support mechanisms were identified in the research papers and depending on the organisation include: preceptorship, the Flying Start programme, trust inductions, training to support NQNs to develop from a novice to independent nurse (Hollywood, (2011), Maxwell et al., (2011), Jamieson, (2012), Jones et al., (2014), Lewis and McGowan(2014), Tracey and McGowan (2015).

Moreover, regarding these important supporting mechanisms, the papers implicitly highlighted the preceptorship programme as the most essential to a successful transition to NQN status (Hollywood, 2011, Tracey and McGowan, 2015). Furthermore, as defined by the Nursing and Midwifery Council, the preceptorship program is a period of guiding and supporting all the newly qualified nurses to make the transition from student to develop their professional career (Nmc.org.uk 2017). With this critical oversight function, the policy of preceptorship is, thus recognised as being crucial to managing the transition to NQN status in which all the six articles talked about in the individual articles (Hollywood, (2011), Jamieson, (2011), Maxwell et al., (2011), Jones et al., (2014), Lewis and McGowan (2014), Tracey and McGowan (2015). In addition, with academics seeing it as vital to enabling NQNs to become independent, safe and confident nurses, as, without this supporting mechanism, it may have a profound effect on NQNs progress (Jamieson et al., 2012).

Concerning the handling of the preceptorship programme itself, however, Tracey and McGowan (2015),have identified that in this period of transition, the newly qualified nurses, midwives and allied healthcare professionals are being supported and by an experienced professional or “Preceptor” for developing their confidence, refine their skills, values and behaviours.

However, Lewis and McGowan (2014) has provided a detailed picture of the preceptorship and its handling of NQNs. Thus, there are inconsistencies in NQNs’ experiences of the preceptorship, but an occasional lack of awareness within NQNs, of what the preceptorship role fully entailed (Lewis and McGowan, 2014). However, in this case, only eight NQNs were studied, making their research findings difficult to generalise and likely to represent merely a snapshot of preceptorship in a specific time and place within the NHS (Lewis and McGowan, 2014)Another key supporting strategy was found to be “Flying Start NHS”, an appraisal and critical reflection tool that was implemented and evaluated in Scotland and subsequently rolled out in some areas in England in 2012, due to its successful evaluation from other NQNs (Nhs.uk 2017). Therefore, within the research papers ‘Flying Start’ Programme was found to be an important supporting mechanism for NQNs, as it supported a life journey for nurses to future career’ (Jamieson et al.,2012).

However, within the research findings, there were some weaknesses of the ‘Flying Start’ programme. Many NQNs felt that they did not have the time to complete the web-based reflection due to time pressures (Jones et al., 2014). Moreover, it also recognised that mentors were not always familiar with ‘Flying Start’ or did not have the time to devote to it (Jones et al., 2014). The implications of this could be that NQNs were not getting the right support in that they're entitled too. Overall, the articles showed that there is support in place for NQNs. However, time and target pressure were the key issues for perceptees and preceptors.

Theme three: The overriding need for emotional resilience in NQNs

According to Health Education England (p.1. 2017) resilience is “a capacity to absorb negative conditions, integrate them in meaningful ways, and move forward’’. As identified by Fenwick et al. (2012) most of the respondents i.e. the NQNs have mentioned confidence and resilience as one of the major factors in the process of preparing the NQNs for the skilled workforce. In a number of empirical evidence, it has been identified that hospitals in the UK are arranging action learning tools to integrate it to the transition support program for increasing the confidence of the nurses with the process of discussion and peer support. As discussed by Missen, McKenna and Beauchamp (2014) the organisational managements need to incorporate formal confidence monitoring tools and peer support groups for improving confidence and resilience level of the NQNS.

Maxwell et al., (2011) highlighted that the transition period of an NQN is a crucial period to acquire resilience due to all the challenges they face within the transition. This is further supported by Jones et al., (2014) who stated that the transition to becoming an NQN requires a process of positive learning which can help support NQNs to be more competent and resilient in their role. As mentioned by Fenwick et al. (2012) the registered nurses and the newly experienced nurses identify the support programs financed by the NHS as one of the major sources of gaining confidence and resilience for further career development.

However, Hollywood’s (2011) interview results found that NQNs who do not have sufficient support or are uncertain about their new role will motivate themselves to study further and develop their knowledge. Hollywood (2011) further stated that NQNs must be responsible and individually gain their competence as they are held accountable. This has been further supported by Lewis and McGowan (2014) and Tracey and McGowan (2015) who both found that NQNs should also find their way through the transition. As, even though support is helpful, the preceptor can only guide the NQN but not make them autonomous and emotionally resilient to the challenges that the transition brings.

The review of the related articles identified that emotional resilience is crucial in facing many challenges as an NQN but they have failed to identify mechanisms those are being helpful in building resilience among the nurses. However, almost all the articles have identified good leadership instrumental in creating resilience. on the other hand, most of the articles have stated that a good and positive experience in the preceptory period has helped in creating confidence among the Newly Qualified Nurses and reduced the level of turnover among the professionals

Recommendations

This literature review has offered a multifaceted recommendation.

• there is clearly a need for further study of the transition from student nurse to NQN status. As seen, the inefficiencies in helping an NQN to reach their full potential is causing retention issues in the NHS, which is affecting the patient care and stretching already limited budgets(Nhs.uk. 2017). Hence, further studies need to be done with structured interviews.
• the role of preceptor needs to be given more importance in clinical settings, and should no longer be treated as an afterthought by NHS trusts who often react to crises, at the expense of fostering the emotional resilience of their next generation of nurses. The forms this could take are numerous, such as: increasing the reduction and remuneration, to be able to focus less on front-line duties, and more on developing the emotional resilience of the NQNs in their charge.
• new methods of helping the NQNs in the transition period needs to be formulated. The development of the Flying Start programme can be identified as mere a beginning, with new software, apps; and administrative tools just waiting to be developed, to make managing the transition process more robust.
• There is an overarching need to standardise the support received by NQNs, with this support often varying wildly across NHS trusts. Thus, in reassessing support policies at a more strategic level, NHS managers should formulate greater accountability in the process and make the processes and milestones of the transition more transparent, and less able to be altered by preceptors who frequently have too much work to focus on the process fully. This systematic and standardised approach must include job responsibility, the extent of support and the specification of hospitals for the nurses, as the mentioned literatures have found a discrepancy in the expectations and the responsibility of the Newly Qualified Nurses.
• For making the financing objective of NHS to the transitional support system for the NQNs, the NHS or the hospital management needs to make strict ethical and behavioural guidelines for both the preceptors and the precepts. As discussed in the previously mentioned articles, workplace bullying is hampering the objectives of the NHS system of a transitional support program for the newly appointed healthcare professionals. These articles have mentioned that such bullying to the less experienced staffs is deteriorating the level of confidence and resilience among the nurses. Hence, it is important to lay down strict policies for this issue.

Conclusion

The research papers considered in this literature review evaluated that NQNs undergo a difficult transition that consists of considerable challenges ahead. Thus, an NQN may face throughout their transition, amongst other factors, a lack of assistance and support, workplace bullying and lack of systemic and managerial facilities in the transitional support system. The reasons underpinning this could be diverse, for example, the interventions not being appropriately implemented, not gaining enough support from qualified members of staff, who themselves are challenged by spiralling workloads, lack of structured guidelines and standardised process and many more. As a predominant focus, this literature review has explored the transition from student nurse to qualified nurse and the effectiveness of the supportIn this contexts a number of articles have been reviewed and most of them have mentioned that the transitional support system has some frailties with itself. These studies have explored the existing support that was already in place for example preceptorship, flying start, trust inductions and the nurse Foundation programme to support NQNs in their transition. It found that the preceptorship is effective. However, preceptors have their workload and may not find an appropriate time to work with perceptees, and this lack of support may cause individuals to become less emotionally resilient. However, this point is currently being academically disputed, with the other research papers stating that the lack of support offered throughout the transition will cause NQNs to adapt and become more emotionally resilient and support themselves. However, this literature review has established that in spite of increased cost responsibility to the NHS, it cannot ignore the importance of the traditional support system for the NQNs. This system has been identified as crucial for providing satisfaction to the nurses and improving the healthcare services in the UK. Hence, it can be identified as an effective and efficient program for the Newly Qualified Nurses.

References:

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