Keywords

Intern-nurses; Transition; Qualitative study; Fiji

Introduction

Strengthening of nursing workforce starts with nurturing intern-nurses at the beginning of their career. The term intern refers to a nurse in the “first stage of their career, recently graduated from university and between the transitional phase of student and qualified nurse” [1]. The internship period is a transitional phase for intern-nurses to learn and equip themselves for a demanding career ahead. According to Duchscher, Zinsmeister and Schafer, and Missen, McKenna, and Beauchamp, intern‒nurses’ experience of transition at the commencement of a professional career is a process of making substantial adjustment to one’s personal and professional life [2-4]. It consists of nonlinear experiences that move intern‒ nurses through a range of changes, including; personal, professional, intellectual, emotive, skill, and role relationship changes. The first twelve months of work experience encompasses a complex array of experience for an intern‒ nurse. According to Hatler, Stoffers, Kelly, Redding, and Carr the first three to twelve months of initial clinical experience is a crucial affair for the intern‒nurses and is a perilous and stressful experience which influences their career [5].

The transition from a nursing student to a practising nurse is a complex and challenging experience for nurses as they adjust to their new professional role. In Fiji, transition includes nursing students undertaking a three-year full time undergraduate nursing program and successfully completing a registration exam with the Fiji Nursing Council (FNC) in order to obtain a practicing license [6]. The registration exam occurs prior to the commencement of a mandatory one-year internship program.

According to Bjerknes and Bjork the transitional phase, intern‒nurses have to familiarize themselves to a new working environment, develop clinical skills, associate with new co-workers and adapt to changing routines [7]. Bjerknes and Bjork define transition as a process of learning and adjustment that an experience to attain skills, knowledge and values required to become a successful member of the healthcare team. Bjerknes and Bjork further state that the process of transition involves shifting from one set of expected positional behaviours to another in a social system; it integrates a social progression in which the intern‒nurse adopts the culture and norms of the workplace. This is similar to Duchscher, who emphasized that it was the quality of the transitional experience that was likely to influence the intern‒nurses’ selfconfidence and retention in nursing [8]. The transitional experience determines how the will perform when they become a registered nurse. Research conducted in several countries provides consistent evidence that this transitioning phase is a challenge for intern‒nurses, even though it has been designed to provide an opportunity for the broadening of clinical knowledge and adapting to a new working environment [9]. According to Missen et al. “intern‒nurses usually perceive their first year of clinical practise as a time of significant stress curtailing from fears of harming a patient, medication errors, litigation, unpreparedness, medical emergency and coping in unpredictable situations” [4]. Similarly, Pfaff, Baxter, Jack, and Ploeg state that first year of nursing practice for many intern‒nurses is a challenging experience as they strive to build confidence in their professional practice [10].

Internationally thousands of intern-nurses enter the workforce each year. In the pacific the number is smaller compared to the larger countries, in Fiji 100 to 200 intern‒ nurses enter the workforce yearly and are distributed amongst the three divisional hospitals. Twenty to forty of these intern‒ nurses spend their internship at Labasa Hospital for a period of one year. Intern‒nurses follow a program which requires them to spend three weeks in each ward of Labasa hospital on a rotational basis. This study has been undertaken to increase the overall knowledge on the experience of intern‒nurses during the transition.

Methodology

A phenomenological qualitative approach was used to explore the transitional experiences of intern‒nurses at Labasa Hospital. According to Donalek phenomenological research studies human experiences through the descriptions provided by the individuals involved. It is a research design that has been widely used in healthcare to study areas pertaining to investigating experiences in real‒world settings. Participants in this study consisted of a convenient sample of 22 new graduate nurses who were employed as an intern at Labasa Hospital for more than six months or had completed an internship at Labasa hospital in the last five years. Their participation was voluntary.

Recruitment of participants was carried out by identifying potential participants through conversation with the Human resource manager. They were approached by the research assistant and given a verbal explanation and a participant information sheet outlining the purpose of the study and the timeframes of the interview. Upon agreeing to participate, each participant was asked to sign a written consent prior to the interview. Data was collected through semi‒structured indepth interviews by a research assistant. Each interview lasted between 40 to 60 minutes. All interviews were audio recorded while unstructured note was taken as well. All interview audio recordings were transcribed verbatim by the principal researcher. Following which a review of transcriptions was carried out to correct errors and to remove references to names, places and significant events to ensure anonymity for the participants. Once the transcriptions were clarified, data analysis was carried out.

Thematic analysis was the choice for data analysis in this study. It was carried out using four steps identified by Green et al. [11]; immersion in the data, coding, creating categories and the identification of themes and subthemes. The principle researcher read and reread each transcript line by line, identifying similar phrases and words than assigned numbers to that word or concept. The coded data that had similar characteristics were grouped together. Once grouping of similar data was completed, descriptive themes were identified to reflect the lived experiences described by the participants.

Ethical approval for this study was obtained from Fiji National University (FNU) College Health Research Ethics Committee (CHREC) and Fiji National Health Research Ethics Committee (FNHREC). Permission was obtained from the Medical Superintendent of Labasa Hospital prior to the commencement of the interviews.

Results

A total of 22 participants took part in data collection through in‒depth interviews over a period of two months. Out of the 22, 10 were currently working as an intern‒nurses at Labasa Hospital while the remaining 12 had completed their internship less than five years ago and currently working in various units at the only Ministry of Health and Medical Services accredited acute care Hospital in Labasa. All the participants were between the ages of 22-26, only one participant was 42 years old. Majority of the participants were females (nineteen) while three were males.

Participants in this study described the commencement of internship with mixed feelings. The following quotes reflect the mixed feelings of intern‒nurses at the commencement of internship.

“I was excited about starting a new job, at the same time nervous about new responsibilities, people and patients” (P4, a 22-year female nurse).

“There is always this thought of whether I will be able to do the right thing or meet the requirements as expected” (P12, a 23-year female nurse).

While the participants had mixed feeling, at the same time they appreciated the support provided by the hospital nursing management and realized the opportunity to acquire knowledge during the internship phase.

“Good support from Director of Nursing and Nurse Unit Managers. They make us feel welcome” (P19, a 24-years female nurse).

“It’s a step by step development; I got the opportunity to mend the gap in knowledge” (P7, a 22-years female nurse).

Participant’s descriptions of transition is grouped into the following sub themes; achievement, learning, responsibility, accountability, and stress.

Achievement

All of the Participants in this research felt that commencing their nursing career as an intern‒nurse is an achievement. Participant’s described achievement in two ways; educational achievement and role achievement.

Educational achievement: Some of the participants described attaining a nursing degree and passing the registration exam as an achievement.

“To have completed my bachelor’s in nursing and get a job was a big accomplishment for me” (P10, a 24-years female nurse).

“I was very happy when I passed the license exam and started working” (P21, a 26-years male nurse).

Role achievement: Majority of the participants also described their new role as an achievement and they commented on their new role associated with their career in nursing.

“It’s a proud moment when you start working” (P2, a 32- years female nurse).

“When you walk in the hospital and one of the clients address you as nurse or ‘nasi’ it is such a proud moment, it makes me feel important” (P3, a 22-years female nurse).

Whilst majority of the participant’s described transition into nursing as an achievement, some of them also acknowledged that it’s a phase of learning new things and making new discovery.

Learning

Some of the participants described their learning experience as having a time to acquire knowledge on the job and up‒skill themselves.

Acquiring knowledge and skills: “Internship is like having opportunity to go through the things you didn’t learn well during student days” (P15, a 25-years female nurse).

“A time to up‒skilling nursing procedures” (P13, a 24-years female nurse).

Some participants also commented that the internship phase of making new discoveries of tasks that they hadn’t learnt before.

New discovery: The participants described making new discoveries with the following comments.

“It’s a time to learn new things” (P18, a 24-years female nurse).

“Every day there is something new to learn” (P14, a 26-years female nurse).

Together with learning, the participants reflected on responsibility associated with the role of a registered nurse.

Responsibility

Some of them stated that there is a change in responsibility as they transition from the role of a student to the role of a registered nurse.

Shift in responsibility: Most of the participants described having to acquire full responsibility when they transition from a student to an intern‒nurse. The following quotes from interview transcriptions describe the shift in responsibility from a student to RN.

“The main difference between being a student and an intern‒nurse is responsibility. As a nurse you are given full responsibility of the patients in the unit” (P11, a 24-years female nurse).

“There is a shift in responsibility from a trainee nurse to a RN, in student days, you do something you know the RN is there to cover your back. As an intern‒nurse you are equally responsible for your actions” (P20, a 22-years male nurse).

Together with shift in responsibility some of the participants voiced the increase in responsibility when commencing their career as a nurse.

Increase in responsibility: The role of an intern‒nurse has a larger scale of responsibilities when compared to that of a student nurse. Comments from three the participants on increase in responsibility are stated below.

“Internship is not just about starting a new job; there are so many responsibilities that come with it” (P16, a 22-years female nurse).

“I think internship is a good way of getting to know the full responsibility of a RN” (P20, a 22-years male nurse).

Additionally, most of the participants agreed that together with responsibility comes accountability.

Accountability

In this study, the participant’s realization of accountability is associated with decision making and increase in accountability with new role.

Decision making: As intern‒nurses some of the participants feel that there is increased accountability in terms of decision making. The following quote rectify the statement.

“During student days you don’t make decisions, you rely on the RNs, when you become an intern‒nurse, its different you make the decision and be accountable for it” (P5, a 25-years male nurse).

One of the participants also stated that it’s important to make sound decisions and be able to justify the decision.

“Decision making should be firm, whatever decision I made I should be able to rationalize why I made that decision, at the end I will be accountable for my decision” (P21, a 26-years male nurse).

Together with decision making the participants acknowledged the increase in liability which includes the clients, the infrastructure and the biomedical equipment.

Increased liability: The following quotes reflect of the increased liability felt by the participants as they transition from being a student nurse to an intern‒nurse.

“You have to be accountable for so many things, the drugs, the patients, and the equipment” (P6, a 24-years female nurse).

“As an intern I have to answer for everything same as a staff nurse” (P18, a 24-years female nurse).

Despite transitional experience being a phase of learning, increase in responsibility/ accountability and a time of role development, majority of the participants feel there some degree of stress associated with it.

Stress

Stress amongst the participants was found to be caused by rotation in different wards, and shift work.

Rotation: The following quotes describe how most of the participants felt while rotating through different wards in the hospital.

“Every rotation is stressful. There are different people, different routines, and different expectations in every ward” (P1, a 22-years male nurse).

“Every ward has a different routine, once you get in it takes about a week to adapt to learn their routine. Once you get adapted, you have to move to another. The movement causes tension” (P2, a 32-years female nurse).

Apart from rotation, shift work is another factor described by the participants as one causes of stress amongst intern‒ nurse.

Shift work: Nurses on shift work at Labasa Hospital have three shifts, each seven and a half hour long. The participants described shift work as:

“Doing shift work is stressful” (P3, a 22-years female nurse).

“Shift work is nerve‒wrecking; I hardly get time for myself” (P20, a 22-years male nurse).

Discussion

The results of this study indicate that transition from student nurses to be a full time registered nurse is a significant phase in the lives of intern‒nurses. During this phase they build on influential experiences that will impact their nursing career as well as determine how well they will perform as a registered nurse. This study adds to the findings of Parker, Giles, Lantry, and McMillan that states that the pressure on intern‒nurses are high [12]. The participants of this research state that they commenced internship with mixed feelings. Even though they viewed internship as an achievement, their excitement is short lived as they recognize the irresistible responsibility and accountabilities that accompany their role as intern‒nurses.

The participants of this research agree with Abdelsalam, Basal, Ebrahem, and Elnagar that transition is a period of learning which comes with overwhelming responsibilities and during the transition intern‒nurses encounter distressing situations that cause stress [13]. According to Shipman transitioning into nursing practice take time, practice and guidance [9]. This study identified five subthemes reflecting transition which are achievement, learning, responsibility, accountability and stress. These subthemes are further divided into categories a discussed below.

The participants described transition as an achievement whereby they had attained academic success by completing their nursing education, gaining a qualification, entering the nursing workforce and joining the healthcare industry. This leads to two categories that reflect achievement; educational achievement and role achievement. The participants described obtaining a qualification and passing the registration board exam as an educational achievement. The participants also indicated their role of becoming a nurse as an achievement as well. During this phase they let go of the well-defined roles of a student and adapt to an unclear role of a registered nurse. These results are in agreement with the study done by Davis which states that as intern-nurses assimilate into the existing nursing culture they acknowledge their new role which is particularly different from that of student nurses which intern‒ nurses were used to in the past [14]. As the intern‒nurses develop into their new role they realise that transition is a phase of learning.

During transition intern‒nurses experience discrepancies between what they learnt in school and what happens in the real world. The participants agree with Goodwin who states that intern‒nurses vitalize the transition phase for learning essential clinical skills and achieving ways to be successful independent nurses [15]. In order to fill in the gap of knowledge and skills between school and real nursing, a phase of learning starts in the lives of inter nurses during transition. The participants of this study reflected learning in two ways; acquiring knowledge and making new discoveries. During transition intern‒nurses are faced with new situations that they may not have come across during their school days. While the intern‒nurses make these new discoveries, they are faced with real circumstances of clinical nursing. While adapting to the new thing they have learnt, intern-nurse is also faced with the responsibilities of being a registered nurse (RN).

According to Ericksen the increase in nursing responsibility intensifies the workload leading to intern‒nurses feeling overwhelmed or having a loss of control [16]. The participants of this study have identified that they feel a shift in responsibility and an increase in responsibility. Shift in responsibility as described by the participants is being faced with new responsibilities that they may not have faced during their clinical attachments. Increase in responsibility on the other hand has to deal with the same situation that they may be facing in the student days but in an intensified manner. These reflections support the work of Odland, Sneltvedt, and Sorlie which states that graduate nurses need to accept their overwhelming responsibility [17]. Similarly, Cubit and Ryan [18] states that intern‒nurses are faced with increased responsibility during transition and Shipman states that as intern‒nurses undergo transition thy are able to understand their multiple roles and accept the multitude of responsibilities associated with it [9]. The participants indicated that the increase in responsibility is associated with increased accountability.

Accountability in nursing is defined as “answerable to oneself and others for one’s own actions” [14]. Fifty four percent of the participants described that the transition from a student to be a nurse is challenging as they are faced with increased accountability. Increase in accountability as described by the participants are either in terms of decision making or increase in liability which defines being held responsible for the many assets in the unit. The findings of this study confirm the notion of Davis who states that nurses are accountable for their practice, the working environment and patient safety [14]. Together with learning and increased responsibility, increased accountability leads to stress in intern-nurses.

The intern-nurses are faced with many forms of stress during transition. This may be due to fear of making mistake, increased workload, additional responsibilities, and enlarged accountability associated with new role, deficit in clinical skills, having to cope with death and dying, time management and working through emergency situations.

The two significant contributors of stress in the lives of intern‒nurses at Labasa Hospital are rotation and shift work. Intern‒nurses are new to the health care system; therefore, it takes them time to adjust to shift work. The finding of this study reaffirms the result of the study done by Evans, Boxer, and Sanber which states shift work as being a new experience for intern-nurses [19]. Adapting to the regularity of shift work is strenuous for the young nurses. Additionally, McKenna and Newton state that shift work compounds stress amongst intern‒nurses. Adding to the intern‒nurses’ misery is the thought of moving to a new ward at the end of every three weeks [20]. Evans et al. state that the rotating nature of the internship programmed leads to a feeling of not being accepted as a part of a team [19]. Furthermore, the prospect of meeting staffs, getting accustomed to a new unit and learning new routines further increases the stress faced by intern‒nurses. According to Ruotsalainen, Verbeek, and Serra the impact of stress is costly to the organization as workers affected with stress may call in sick and overtime will be created which is an addition to the financial burden of the organization [21].

Although it is common to use qualitative research methods in health care research, this was a reasonably small convenience sample (n=22) to provide a reflection of the entire nurse population in Fiji. Additionally, the study was conducted at one research site where all of the intern‒nurses attended one facility internship program based at a small hospital and it would not be wise to generalize the finding of this study to reflect the other hospitals in Fiji.

Conclusion

The findings of this study provide insights on the transitional experiences of Intern‒nurses. Enabling a smooth transition for the intern‒nurses is a critical issue for today’s health care system. The internship rotation program provides intern‒ nurses with opportunity to gain knowledge and skills necessary for carrying out quality and safe nursing care while utilizing the nursing processes but further support is needed to facilitate a better transitional experience.

In conclusion, intern‒nurses can be provided with support by colleagues, nurse leaders or the organization. Colleagues may provide assistance through feedback, debriefing and praise. Organizational support can be provided through structured preceptor‒ship programs which can improve job satisfaction, reduce stress and anxiety and increase confidence of the intern-nurses [13]. Intern-nurses are the future of nursing profession therefore; there is an immediate need to focus on the support they receive during their transition. The development of sustainable support networks for internnurses will not only help them, but it will strengthen the nursing profession and aid in creating a more supportive work environment [22]. This will lead to better patient care and improved organizational outcomes.

Finally, the information obtained through this study will enable the management and nursing leaders of Labasa Hospital to facilitate a better experience for intern-nurses while transitioning into the role of registered nurses. A positive transitional experience will enable intern-nurses to become knowledgeable and proficient nurses of the future.

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