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Transition Theory

Updated June 2014

Video on Transition

Stages of Transition Model

Transition Shock Model

BUILDING A GROUNDED THEORY


OVERVIEW OF THEORY ORIGINS

The body of work presented here, and that which frames and grounds this organization of support represents an extensive and comprehensive study and research spanning 15 years (1998-2013). The intent of this program of research is to continue to examine, build upon and mature aspects of the new nursing graduate (NG) transition experience such that an accurate overall representation of this experience and the processes encompassed within it can be confidently applied by the scholarly community. The purpose of such application is to provide representative support for this experience and to advance the dialogue around the issues inherent in the new nurse's initial professional role adjustment.

If we are to not only recruit and retain NGs, but motivate and inspire the future generations of our profession then we must come together in creating a strategic plan that can reflect, address and continually monitor the challenges NGs face when being formally introduced into their professional community. It is this collective effort that has the potential to yield transformative change within the discipline, for while the initial professional role transition of the graduate nurse is itself a unique stage in their professional journey it should also be considered a magnified reflection of the realities all nurses face on a daily basis. As such, the evolving transition experience of the NG has the potential to unite and advance the entire profession by making visible the contemporary challenges and triumphs of the whole nursing community.

The substantive new graduate nursing transition theory presented here constitutes a relatively 'narrow' view of the overall socialization of this new professional. Larger, metatheoretical frameworks of transition transcend time, demographic, context and individual nuances. This theory, being substantive, speaks only to the experience of new nurses at the interface of their student-practitioner lives (post 'orientation' to the workplace up to 12 months of professional practice). While what I have revealed through this research program has resonated remarkably well anecdotally with experienced nurses making role transitions within the profession (for instance from direct-care nurse to nursing educator), and has been identified as congruent with the initial role transitions of professionals from other healthcare disciplines (social workers, pharmacists, physicians, dieticians), it is not evidentiary of the lived experience outside of the newly graduated nurse.

Further, I would caution that it is not enough to simply understand what new nursing graduates experience during their journey from student to practitioner; this is but one phase in their socialization to the profession of nursing and a relative first step in their ongoing professionalization as nurses. Having said that, I believe that it is by seeking to understand the lived experience of the newly graduated nurse that we become aware of the challenges they face not only as nurses but as individuals within social, economic, political, developmental, cultural, physical, professional and institutional (workplace and education) contexts. It is my hope that through this deep understanding, we can attend to the socialization and professionalization processes required to support the kind of profession, and consequently, the quality of healthcare we are able to offer our communities.

Along my journey in this topic area, I think the most unanticipated, but undoubtedly the most fulfilling outcome of my work in this area has been the gentle but persistent “voice” of the new graduate that has insisted on being heard. It has been clear through the process of my research, study and ongoing work with NGs that far too many of them still experience role stress, moral distress, discouragement and disillusionment during the initial months of their introduction to professional nursing practice, particularly in acute care. My work with hundreds of graduates has revealed a staged, mostly progressive and nonlinear process whereby new greduates explore, discover, engage, separate, critique, embrace and endure their transition to professional nursing practice.

While the elucidating of a theoretical construct that can help us to understand the new graduate experience is the obvious academic outcome of my work, it is the narration of the new graduate story of transition as told by me through the shared experiences of all the new graduates with whom I have had the privilege of interacting across Canada and the US that has truly transformed me. This body of work has been, in many ways the most illuminating, clarifying and crystallizing experience that I have ever had. Perhaps the compelling nature of their collective story is that it poignantly illustrates a proverbial “coming of age” and as such, resonates in some way, at some level, with all of us. There is the excited anticipation of arriving at a long-awaited and hard-earned goal to realize, as in this case that “it’s just a job, like every other job” you’ve ever had. While embarking on a professional life has its moments it is often ultimately revealed to be more reality than romanticized fiction - more bee than honey. This account reflects the age-old adage that “all is not as it seems” or, more to the point what we dreamed; this is a story about growing up. 


NEW GRADUATE TRANSITION CONTEXT

Providing quality health care depends upon understanding what constitutes a quality nursing work environment and then taking steps to provide for and support that environment. Numerous studies in North America have provided extensive evidence relating patient care outcomes to the availability of competent and qualified nursing care. Despite further correlations between a shortage in quality nursing human resources and public health risk, demands for full-time nursing professionals continue to exceed the rate at which new nurses are graduating from educational institutions. With current shortages of nurses straining an already taxed healthcare system, the stark projections of escalating attrition due to an aging workforce, and the premature exit of nurses out of the workplace because of physical and emotional exhaustion are rapidly becoming unacceptable consequences of a system out of control. Experts claim that the current nursing shortage is unlike anything we have experienced to date. It is the outcome of a long-term, complex composite of market, technological, and societal influences that have eroded the ability to respond to cyclical changes in the need for expert nurses. A lack of respect, an unwelcoming hospital culture, inappropriate utilization of nursing knowledge, a focus on fiscal management rather than quality work environments, and attractive alternatives to hospital nursing are primary contributors to the current acute-care nursing workforce deficiencies. A recent report of nursing workforce trends in five countries (Canada, the United States [US], England, Scotland, and Germany) showed strikingly consistent symptoms of distress suggestive of:

  • Fundamental problems in the design of nursing work,
  • Inadequate staffing quotas available to cope with elevated acuity and census figures,
  • Increases in worker absenteeism and subsequent escalating costs of nursing care provision,
  • Qualitative evidence of healthcare administrations that are out of touch with the voices of struggling nurses, and
  • Reports of an increased tendency for younger nurses to show greater willingness to leave their hospital jobs.

Compounding this are reports claiming that more than 40% of NGs in the US are choosing not to practice nursing upon graduation. The majority of those who begin practicing as professional nurses do so in a hospital setting and a concerning 33-61% of these graduates have been cited as changing their place of employment or leaving the nursing profession within the first two years.

Perhaps most troubling are statistics indicating that less than half of the current nursing workforce would recommend nursing as a career option, and a startling 25% would actively discourage someone from going into nursing. Renowned workforce analysts have projected that a 40% annual increase is required in the enrollment of young people in undergraduate nursing education programs just to stem the impact of the workforce attrition expected by 2010. Others warn that the failure to understand and address the historical, sociopolitical and economic issues that underpin and subsequently perpetuate the stressful, oppressive and devaluing context of the acute-care practice environment may well eradicate any hope of sustaining a viable professional nursing workforce. 

We know that the movement of NGs between institutions, or out of the profession altogether can be primarily attributed to five factors:

  • Emotional exhaustion secondary to competing professional demands, excessive workloads, and a sense of powerless to effect change,
  • Horizontal violence and abuse from seasoned RN colleagues,
  • A plummeting professional self-concept and self-confidence within  NGs without sufficient consideration for the impact of this change on their professional motivations and inspirations,
  • Hospitals that are severely understaffed, with RNs subsisting within a culture that is resistive to new ideas and burdened by negative attitudes about nursing and health care, and,
  • Undergraduate educational and employment institutions that do not consistently or comprehensively provide formal knowledge transfer or professional integration programs of support such as undergraduate curricula on transition preparation, seasoned-novice nursing mentorship and preceptorship programs, NG internships or residencies, transition facilitator or NG advocacy initiatives or extended workplace orientations.  

While the most overt cost to employers may be seen as the replacement of exiting nurses, an even greater cost may be a threat to the health of the public as a whole. Increased patient morbidity and mortality rates are a natural consequence of new and experienced nurse burnout that is secondary to inadequate staffing, job dissatisfaction and the moral dissonance of the practicing nurse. Near-miss research clearly warns of the dangers of expecting GNs to practice without access to experienced colleagues for clinical collaboration and leadership. Finally, limited human resources dictate the immediacy of implementing creative programs that support role appropriation of various nursing professionals for the purposes of optimizing performance throughout all scopes of nursing practice. As a result of deficits in quality nursing-care provision that may be inaccurately represented as primarily commodity-based, the newest inductees into the profession are being recruited and hired into practice areas where decision-making and clinical judgment expectations exceed the graduates’ developmental capabilities. Graduates are at risk of buckling under the strain of workload expectations that are unprecedented and work environment stressors that have reached unacceptable levels. 


UNDERSTANDING TRANSITION AS A CONCEPT

The importance of understanding the process of role transition in nursing relates to the above mentioned challenges for institutions of healthcare, schools of higher learning and policy makers in this country to both understand and respond to issues inherent in the socialization process of NGs to the contemporary professional practice environment. Concurrently, it is the enormous frustration inherent in being unable to practice as fully-functioning professionals within the hospital system that is underlying the current job dissatisfaction of NGs and driving these energetic and motivated young nurses out of acute care and out of the nursing profession altogether. While it is clear that many NGs experience, albeit at varying intensities, role performance stress, moral distress, discouragement and disillusionment during the initial months of their introduction to professional nursing practice in acute care, it is only recently, through the articulation of this theory, that we are gaining greater insight into what relationships exist between these experiences and the passage of time. As important to the objective of this research are the connections that can be drawn between the challenges faced by NGs practicing in acute care and the broader professional issues being cultivated within the current context of nursing practice. 

Reflected in the foundational literature and research that serves as the foundation of this theory is the knowledge that up to now we have had few contemporary models that explicate the stages through which NGs advance during their initial professional socialization journey. The majority of studies target specific points in time (3, 6, or 12 months post-registration) or access retrospective participant reflections to explicate an experiential perspective of the transition experience. While more focused studies provide general information regarding the experience of transition, this theory is the first to extrapolate our knowledge of transition to a formal framework for use in the development, implementation and evaluation of initiatives aimed at facilitating the NG transition. It is hoped that this theory will support the distilling and distinguishing of salient, unavoidable and necessary aspects of transition from the more transient, context-related and yielding elements of transition for which support strategies can be effectively implemented.  


THEORETICAL FOUNDATIONS

The generation of this emerging theory originates from a now 13-year program of research encompassing qualitative studies in the area of new graduate transition and an ongoing contemporary literature review of the transition experience of the new NG. My initial study, conducted in 1998, consisted of a 6-month phenomenological exploration of five new nurses navigating their initial introduction to professional practice. The second study, conducted in 2001, extended over a period of 12 months and was an exploration of the experiences of four new graduates and five seasoned nurses. These graduates were studied as they integrated into an emergency room environment immediately after graduating from a Canadian undergraduate BScN nursing program. The third study was conducted by Dr Leanne Cowin out of Australia. I was asked to complete a retrospective analysis of the qualitative data collected in this three-part study examining graduate nurse self-concept and retention plans. In my doctoral work of 2007, I explored the transition journey of 15 newly graduated nurses over 18 months. For this study, I employed a generic qualitative approach to data collection, using a grounded theory process to guide the ongoing analysis and interpretation of the emerging data. Initial semi-structured interview templates were created for the 1, 3, 6, 9, 12 and 18-month data collection periods based on my previous program of research on new graduate transition. These instruments were then modified as the data emerged. In addition, participants completed pre-interview questionnaires and submitted monthly journals detailing their experiences. Finally, focused group discussions, informed and guided by prior interviews, journaling data and my ongoing study were conducted during identical time periods with a separate group of participants originating from the same nursing program. A dynamic interplay between inductive and deductive processes permitted a fluid movement between data analysis and further data acquisition.

As of September 2011, I am actively engaged in a research study to explore the initial professional role transition of acclerated degree nursing graduates (those graduating with a Baccalaurate in Nursing after having acquired a non-nursing degree prior to entry into their nursing program). As well, in the summer of 2011 I embarked on an international study of men transitioning to professional practice as nurses. Data collection for both of these studies concluded August 2012 and I am writing up this research.

Further to the research conducted, I continue to review thousands of publications related to new graduate transition, hospital nursing and trends in professional nursing practice, over 750 of which have been directly related to the transition or integration of new nurses into work settings. In my role Chairing an annual internationally attended conference on research, innovations and capacity building around the integration of new nurses to professional practice, I am fortunate to be privy to some of the latest work being purported to address the challenges of this professional milestone.


GROUNDED THEORY

As a researcher, I am a strong proponent of Glaser’s concept of theoretical emergence and adhere closely to its foundational tenets; in particular by consistently and frequently revisiting Glaser’s classic question “what is actually happening in the data?”, and trusting that emergence will occur. Having said that, my long-standing relationship with the topic of new graduate transition and my immersion in the community being studied makes it difficult to deny a constructivist influence upon the process that has been used to clarify, verify and explicate the truth of my data interpretations. For those familiar with constructivist approaches to GT, I am fond of the way Charmaz elucidates the essential nature of entering the phenomenon being studied, claiming that the researcher’s ability to sense, feel, and fathom what the experience is like validates the humanity of the participant and gives voice to that which would otherwise remain silent. In the process of interacting with data and its sources, she claims that researchers unavoidably shape, and are shaped by that interaction regardless of the point at which they may find themselves on that relational continuum. Personally, I do not believe that Glaser's foundational approach to GT and constructivist epistemology are counter-intuitive. It is the assurance, as much as any researcher 'as instrument' can ever offer, that one is truly grounded in the data such that the theory 'emerges' out of the same and resonates with those embedded in the study context, that determines whether or not a theory is grounded.

Each study that followed my initial exploration of the transition experience of new graduates serves as a theoretical sampling of the transition experience. Theoretical sampling is defined by all grounded theorists as the process of ongoing data collection whereby the analyst jointly collects, codes, and analyzes his data and decides what data to collect next and where to find it, in order to develop a theory as it emerges. The explicit, consistent, and persistent use of theoretical sampling is the distinguishing ingredient of the GT approach to research that sets it apart from other methods. Each of my post-MN studies is itself a theoretical sampling resulting from my prior work. Given that I continue to participate in ongoing data analysis for the purpose of building on emerging concepts, a degree of preconception has been unavoidable as the theory has evolved and, in fact, methodologically necessary. The difference between this notion and the idea that I might have forced unsubstantiated codes out of the data is grounded in an understanding that my preconceptions have been generated from original data on the professional role transition of NGs into acute care and continue to 'fit' the context of professional role transition for the newly graduated nurse. As such, it is anticipated that continued inquiry over time will provide for the ongoing emergence of conceptual and theoretical ideas, allowing them to evolve as well as ground and guide further inquiry. 


CODING AND ANALYZING DATA

It is only reasonable that I offer my process and perspectives on my data coding and analyzing approaches. The primary strategy in the integrated coding and analyzing stages of the GT theorizing method, and one which is consistently applied despite the researcher’s philosophical or research orientation is Constant Comparative Analysis (CCA). This technique of contrasting data first against itself, then against evolving original data, and finally against extant theoretical and conceptual claims facilitates the emergence of knowledge that provides us with relevant predictions, explanations, interpretations and applications. Glaser and Strauss’s original GT approach to research clearly places the researcher in the position of patient listener, waiting for the emergent theory with ‘abstract wonderment’. Glaser was quite clear on his sense of the relationship of the researcher to the researched when he stated that the goal is not to tell people what to find or to force, but what to do to allow the emergence of what is going on. I have always taken into account cautionary notations by Glaser (1978) and Strauss (1987) that draw attention to the rules governing levels of coding. As such, I frequently ask a prescribed set of questions of the data from the onset: 1) what is the data a study of? 2) what category does this line or group of lines indicate? and 3) what is actually happening in the data? This microanalysis is duly noted by me and I have made exceptional effort to re-enter the data time and time again, in various forms, such that the microanalysis can yield a dense, rich theory. As well, due to my long-standing history with the topic, I have intentionally employed data rigor strategies that safeguard me against establishing ‘pet’ themes and ideas unless they were found to have emergent fit. This has been particularly relevant in my most recent work with accelerated degree students as the nuances and distinctions of their professional role transition require significant rigor with regard to assumptive preconception. I continue to seek external (i.e., research process and subject content experts) reviewers of my work that can validate, clarify and challenge my ideas, and as a result of my embeddedness in the new graduate community, I frequently return my theory to contemporary new graduates for their comments and questions.

The natural emergence of the theoretical codes you see in my models came only after repeated re-entry processes of data analysis that ultimately provided me with a consistent sense of two overall emergent cores entitled Transition Shock and Stages of Transition. The latter’s three subsequent sub-core variables were laboriously but ultimately decidedly identified as Doing, Being, and Knowing. Continuous and repeated examination of the data assisted in the development of the aspects related to these core variables and processes. Along with an intentionally circular analysis of the relationship amongst established codes I theoretically conceptualized through advanced coding, which consists of an explicit process of expansion of the previously coded concepts. Glaser understands this process to be a weaving back together of the necessarily fractured data through the use of a coding framework that assists the research to connect the causes, contexts, contingencies, consequences, co-variances, and conditions of an evolving theory. 


MEMOING

Writing memos is a constant, persistent and precedent facet of the GT research process that begins with the initiation of data coding and continues to the very end. This theoretical writing up of ideas, separate from the data focuses on relationships between codes and their properties as they become evident to the analyst; memo writing captures the frontier of the analyst’s thinking. Although memoing occurs throughout the research process, Glaser adamantly warns researchers that if they skip this stage by going directly from coding to sorting or writing theyb are not doing grounded theory. The unequivocal importance of this stage in the approach to my research is underscored by the length of time I have spent embedded in the context of new graduate transition, both as a result of my ongoing research program and my founding and ongoing development of Nursing The Future and my work with countless new graduates across the country on an ongoing basis.

I have frequently interrupted the research process and created many opportunities to engage in theoretical and conceptual reflection. I carry a digitial recorder with me at all times, making notes that continue to add to an exhaustive collection of theoretical ideas that have allowed me to raise the data I have acquired to a conceptual level, assisted me to develop and grow the properties and aspects of each stage and the processes inherent within, and afforded me substance with which to hypothesize connections between concepts, ideas and data as the theory and models have emerged - I appreciated Glaser's 'permission' during a recent skype session with him, to integrate this as simply 'more data'. My ongoing publications, management of Nursing The Future ™, development of the organization’s new graduate leaders, and my exhaustive professional speaking engagements and consultation on the topic of NG transition continue to enrich my theory.  


STAGES OF TRANSITION THEORY

A COMPLETE and detailed outline of my theory can be found by CLICKING HERE.

The Stages of Transition © model incorporates a journey of becoming where NGs progress through the stages of doing, being and knowing. The initial 3-4 months of the NGs’ journey is an exercise in adjusting and adapting to, as well as accommodating what they find in the realities of their new work, professional and life worlds. For the new graduate, there is little energy or time to lift their gaze from the very immediate issues or tasks set before them, and their “shock” state demands a concerted focus on simply “surviving” the experience without revealing their feelings of overwhelming anxiety or exposing their self-perceived incompetence. The second stage of professional role encompasses the next 4-5 months of the NGs’ postorientation period and is characterized by a consistent and rapid advancement in their thinking, knowledge level and skill competency. As this period progresses and the NGs gain a comfort level with their professional roles and responsibilities, they are confronted by inconsistencies and inadequacies within the healthcare system that serve to challenge their somewhat idealistic pregraduate notions of the profession. An increased awareness of the divergence between their professional “self” and the enactment of that self in their new role motivates a relative withdrawal of the NGs from their surroundings. The primary task for these graduates at this stage is to make sense of their role as a nurse relative to other healthcare professionals and to find a balance between their personal and professional lives. The third and final stage of evolution for these nurses during the initial 12 months of their careers was focused on achieving a separateness that both distinguishes them from the established practitioners around them and permits them to reunite with their larger community as professionals in their own right. With an increase in both familiarity and comfort in their nursing roles, professional responsibilities and relationships with coworkers, the NGs have the time and energy to begin a deeper exploration and critique of their professional landscape, making visible the more troubling aspects of their sociocultural and political work environments.

Likely fed by a residual exhaustion from prior stages, the NG may express a growing dissatisfaction with shiftwork, the conditions of their work environment and their relative powerlessness to effect change within that environment. For some, this may simply be a case of adjusting to the work world for the purpose of achieving a sense of job satisfaction. For others, sacrificing particular professional expectations and aspirations and conceding to what they perceive as inadequacies in the system within which they will spend their life working is terminally demotivating and inspires a search for alternate avenues of professional fulfillment (e.g., changing employment, leaving the province and country, making plans to return to school or disengaging from and exacting a distinct separation between work and home life).  The whole of this journey encompasses ordered processes that included anticipating, learning, performing, concealing, adjusting, questioning, revealing, separating, rediscovering, exploring and engaging. While this journey is by no means linear or prescriptive nor always strictly progressive, it is evolutionary and ultimately transformative. Further to this, it can be assumed that ongoing but transient regressions will be experienced by the graduates and may be precipitated by the introduction of new events, relational circumstances and unfamiliar or complex practice situations or contexts into the graduates’ assumed location on the transition continuum that is represented by this theory.


TRANSITION SHOCK

Transition Shock © was the initial core variable to take shape from the data, and did so quite persistently and dramatically. While I did not set out to rewrite Dr. Marlene Kramer’s (1974) reality shock theory, the unrelenting presence and significance of the findings have granted me the confidence to move forward with an always cautious sense of clarity and a deep level of conscience that has served to empower rather than dissuade the development of this idea. The theoretical construct of transition shock focuses on the antecedents (aspects of the new graduate’s roles, responsibilities, relationships and knowledge) that both motivate and mediate the intensity and duration of the experience and qualify the early stage of professional role transition for the NG. The detail offered in relation to these antecedents is intended to facilitate a more comprehensive use of the model by identifying multiple root issues and events through which the transition experience might be further understood and supported. This work builds and expands on Kramer’s (1974) theory by demonstrating that the NG engaging in a professional practice role for the first time is confronted with a broad range and scope of physical, intellectual, emotional, developmental and sociocultural changes that are both expressions of, and mitigating factors within the experience of transition. These factors may be further aggravated by unfamiliar and changing personal and professional roles and relationships as well as unexpected and enhanced levels of responsibility and accountability that students are unable to be afforded during their education. Further to this, the current assumption underlying the contemporary transition experience is that NGs will be able to apply clinical knowledge to a new context of practice that may be as yet untried, may be contextually unrecognizable to the novice practitioner, or may be simply unknown. An impressive finding and one which serves as a core variable in the experience of transition shock is the “surprise” expressed by participants as they move into a professional workplace role. The predominance of this variable reveals an inadequacy in the preparation of senior students for the reality of the transition experience. Furthermore, the extent of the struggle to adjust to their new reality, and the fact that while the experience qualitatively changed over time but did not significantly abate by the 12 month mark of their transition, suggests that insufficient orientation and support existed for these new professionals in the workplace. Elucidating and then edifying the stages of role transition that occur for the NG during the initial 12 months of their introduction to professional practice was an emerging finding that indeed emanated fluidly from both a theoretical and representative (i.e. model) perspective.


RESEARCH PROGRAM

I joined the professoriate of the University of Calgary Faculty of Nursing in 2009 where my program of research in transition continues to explore, understand and contribute to the advancement of the following issues:

  • Transition facilitation strategies that address the various stages of NG transition.
  • Development of a Professional Role Transition Risk Assessment Instrument (PRT-RAI) (AWARDED FUNDING FOR DELPHI PROJECT TO IDENTIFY INSTRUMENT ITEMS) that will allow for the assessment of underlying causal variables for the transition experience of individual graduates. This tool is expected to allow service providers and nursing educators to determine the level and primary source of new graduate transition stress (roles, relationships, responsibilities and knowledge), further facilitating the specific targeting and individualizing of transition facilitation strategies with the end goal of reducing the overall intensity of transition shock.  
  • Educational transition preparation that utilizes regional industry-based seasoned practitioners and nursing unit managers as anticipatory socialization agents, facilitates the development of a transition facilitation program within the healthcare system, implements and evaluates the impact of transition preparation, transition facilitation on the professional role transition experience of the NG into acute care.
  • The professional role transition into acute-care nursing of students completing a second undergraduate degree in nursing (Accelerated Track  BScN Program) AT DATA WRITING STAGE.
  • The experience of male NGs making their initial entry into professional practice AT DATA WRITING STAGE.
  • The perceptions, anticipations and expectations of professional role transition for senior undergraduate Registered Nursing students While faculty at UC, I supervised MN CANDIDATE KANDIS HARRIS IN THIS WORK (ntfkapell@gmail.com)
  • The evolving perceptions of leadership by newly graduated nurses as they progress through the stages of transition While at UC, I supervised MN CANDIDATE ANNA-MARIE OFFIAH IN THIS WORK (ntfallen@gmail.com)
  • Using Duchscher's nursing transition model as a framework, examine the evidence related to the transition experiences of other professional disciplines. Compare existing evidence and begin a program of research with the intent to develop a larger theoretical construct that encompasses the whole of professional role transition.

In 2010 I served as Lead for a project funded by Alberta Health and Wellness (AHW) to explore the transition facilitation strategies being implemented in the province of Alberta for newly graduated  nurses. I have developed a framework that uses the Stages of Transition to accent the 'phases' of support required as newly graduated nurses evolve through the initial 12 months of their transition to professional practice. Dr. Graham MacCaffrey, Dr. Jeanne Besner and Sheila MacKay assisted me as developers on this project.

I have written the Canadian version of 'Role Transition' in the textbook entitled: 'Leading and Managing in Nursing' by Elsevier Mosby (http://evolve.elsevier.com). This book was published in the Winter of 2014.

My newest book, 'From Surviving to Thriving: Navigating the First Year of Professional Nursing Practice' (2nd Ed) was published February 2012. I continue to be very excited about this book as I see it being used globally as a framework for new nurse orientation/residency programs, providing these novice practitioners and their supporters with clear and pragmatic approaches that allow for the navigation of the Stages of Transition and Transition Shock. I recently received this message from an educator in New South Wales, Australia:

October 22, 2013: My name is Naomi, I am a Clinical Nurse Educator from Cardiology in Sydney, and have found your theories on New Graduate transition to be a fantastic foundation for the program myself and some colleagues put together. We had a number of issues that led to the redesign of our New Graduate orientation program, namely a reduction in supernummery time from 5 days to 1, as well as an increasing number of clinical incidents involving New Grads. We were frustrated because we had felt that we had given the NG nurses all the theoretical information that they needed in order to do their role, and could not understand how they were not applying it and continued to make mistakes when we felt they should know better, or ask before doing. Reading your work on the New Graduate transition on doing, knowing and being was our light bulb moment. We needed to strip back everything we were doing, and focus on initially giving them tools to keep themselves and the patients safe (for us, we felt that was a set of skills and tools in communication, patient assessment and process for escalation), and then work to develop a supportive program in which they could develop their theoretical knowledge, as well as critical think and clinical reasoning skills over time and in a safe learning environment. We needed to create a space where they could come together, support each other as well as be supported by us as educators through their transition. You will be happy to hear that this worked! Our New Grads are not making as many mistakes and are more engaged in their learning than any other group that has come through our service in the last 3 years. I am just a little biased, but I feel we now have a supportive program that creates a solid foundation for New Graduate nurses who are at the start of their careers.

So thank you for giving us out 'light bulb' moment, and helping us to better understand the transition that our New Grads are going through so that we could design an orientation program that better supports their transition whilst keeping the new graduate and patient safe!

Regards,

Naomi Van Steel

Jayne Hartwig, nursing educator and Coordinator of the New Graduate Transition Program in South Australia has been working with my theory for several years now.  Here is an excerpt from a recent email from her:

October 21, 2013:  Dear Judy, just sending another update.  I presented about my Transition Program, explained how it is based on your wonderful theory and then went on to outline the essential components of how we support our Grads and Preceptors. I could have talked for hours! I was overwhelmed by the number of people who gave positive feedback and who have since emailed me for more information about what we do at WCH. I have also directed many people to your website and suggested they purchase a copy of your book! All of this reminded me again of why I love my job so much!

Jayne Hartwig RN, BN, Grad Dip Nurs (Nurse Ed), Grad Cert Health (Paeds) | Nurse Education Facilitator Transition To Professional Practice Programs | Centre for Education and Training | Women's and Children's Health Network | Women's & Children's Hospital Campus

Level 1 Samuel Way Building | 72 King William Road, NORTH ADELAIDE 5006 t: 8161 8606 | p: 4303  | f: 8161 8527 | e:jayne.hartwig@health.sa.gov.au

Most recently, I have partnered with Dr. Jane Lemaire (UofC Medicine) and Dr. Jean Wallace (U of C Sociology) in a study that explores the transition experience of physicians making a professional role transition to independent licensure practice in Alberta. While we are using a phenomenological lens to initiate this work, it is our intent to use this research to begin to understand how the theoretical models I have constructed in nursing can be used to understand the experiences of physicians. We began the DATA ANALYSIS PHASE of this work in June 2012 and expect to be publishing on this shortly.

I hope my work can serve as a platform to both understand, and seek to support the professional transitions of the newest members of our profession. This theory is currently being used to frame orientation and integration programs for new nurses in Canada, the US, Australia, New Zealand and Japan - for a list of these programs please contact newgraduates@nursingthefuture.ca.

To view Dr. Duchscher's Curriculum Vitae.

To contact Dr. Duchscher write her at newgraduates@nursingthefuture.ca