Role Transitions

Role transition can be a complex experience.

After completing this chapter, you should be able to:

• Discuss the concept of transitions.

• Identify the characteristics of reality shock.

• Compare and contrast the phases of reality shock.

• Identify times in your life when you have experienced a reality shock or role transition.

• Describe methods to promote a successful transition.

Welcome to the profession of nursing! This book is written for nursing students who are in the midst of transitions in their life. As a new student, you are beginning the transition to becoming indoctrinated into nursing, and sometimes it is not an easy transition. For those of you who are in the middle of nursing school, do you wonder if life even exists outside of nursing school? To the student who will soon graduate, hang on; you are almost there! For whatever transition period you are encountering, our goal is to help make your life easier during this period of personal and professional adjustment into nursing. We have designed this book to help you keep your feet on the ground and your head out of the clouds as well as to boost your spirits when the going gets rough.

As you thumb through this book, you will notice that there are cartoons and critical thinking questions that encourage your participation. Do not be alarmed; we know you have been overloaded with “critical thinking” during nursing school! These critical thinking questions are not meant to be graded; instead, their purpose is to encourage you to begin thinking about your transition, either into nursing school or into practice, and to guide you through the book in a practical, participative manner. Our intention is to add a little humor here and there while giving information on topics we feel will affect your transition into nursing practice. We want you to be informed about the controversial issues affecting nursing today. After all, the future of nursing rests with you!

Are you ready to begin? Then let’s start with the real stuff. You are beginning to experience transitions—for some of you, just getting into nursing school has been a long struggle—and you are there! For others, you can see the light at the end of the tunnel, as graduation becomes a reality. Nursing is one of the most rewarding professions you can pursue. However, it can also be one of the most frustrating. As with marriage, raising children, and the pursuit of happiness, there are ups and downs. We seldom find the world or our specific situation the exact way we thought it would or should be. Often your fantasy of what nursing should be is not what you will find nursing to be.

You will cry, but you will also laugh.

You will share with people their darkest hours of pain and suffering, but

You will also share with them their hope, healing, and recovery.

You will be there as life begins and ends.

You will experience great challenges that lead to success.

You will experience failure and disappointment.

You will never cease to be amazed at the resilience of the human body and spirit.


What Are Transitions?

Transitions are passages or changes from one situation, condition, or state to another that occur over time. They have been classified into the following four major types: developmental (e.g., becoming a parent, midlife crisis), situational (e.g., graduating from a nursing program, career change, divorce), health/illness (e.g., dealing with a chronic illness), and organizational (e.g., change in leadership, new staffing patterns) (Schumacher & Meleis, 1994).


Transitions are complex processes, and a lot of transitions may occur at the same time.

What Are Important Factors Influencing Transitions?

Understanding the transition experience from the perspective of the person who is experiencing it is important because the meaning of the experience may be positive, negative, or neutral, and the expectation may or may not be realistic. The transition may be desired (e.g., passing the NCLEX® Exam) or undesirable (e.g., the death of a family member, after which you have to assume a new role in your family).


Often, when you know what to expect, the stress associated with the change or transition is reduced.

Another factor in the transition process is the new level of knowledge and skill required, as well as the availability of needed resources within the environment. Dealing with new knowledge and skills can be challenging and stressful and can lead to a variety of different emotions related to the expectation of the new graduate to be competent (Box 1.1). This will resolve as your confidence grows and you have more understanding of the concept of how to “think like a nurse.”

Transitions are a part of life and certainly a part of nursing. Although the following discussions on role transition and reality shock focus on the graduate nurse experience, there are many applicable points for the new student as well. As you learn more about transitions, reality shock, and the graduate nurse experience, think about how this information may also apply to your transition experience into and through nursing school (Critical Thinking Box 1.1).

Looking back, what transitions have you experienced? What transitions are occurring in your life now? Has your entry into, as well as progress through, nursing school caused transitions in your personal life? Has your anticipated job search caused transitions in your professional as well as personal life?

Transitions in Nursing

The paradox of nursing will become obvious to you early in your nursing career. This realization may occur during nursing school, but it frequently becomes most obvious during the first 6 months of your first job.

Health care organizations are very concerned about your transition experience and job satisfaction during that first 6 months of employment. Have you been hearing about “evidence-based practice?” Well, it is working for you now! During the first 6 months of employment, new graduates need a period of time to develop their skills in a supportive environment. Employee retention and job satisfaction are key issues with the hospital; confidence in performing skills and procedures, nurse residency programs, and dependence versus independence are key graduate nurse issues driving this research. The well-being of the graduate nurse and the ability to deliver quality nursing care during the transition period have sparked research to validate the need for special considerations of the graduate nurse experiencing transition (Casey et al., 2004; Godinez et al., 1999; Lavoie-Tremblay et al., 2002; Steinmiller et al., 2003; Duchscher, 2008; Duchscher, 2009; Varner and Leeds, 2012Spector, 2015a). With identification of the basic problems encountered by new graduates during this first 6 months, there is a concerted effort to begin to meet the special needs of the graduate nurse and assist him or her to “think like a nurse” (Research for Best Practice Box 1.1).


BOX 1.1Stresses Reported by New Graduates Related to 6 Crucial Competency Areas

1. Communication

Calling or talking with a physician, completing shift reports, addressing patient requests, and resolving conflict

2. Leadership

Lack of delegating skills

Anxiety associated with collaborative teamwork

3. Organization

Lack of organizational and management skills to prioritize care

4. Critical thinking

Difficulty with clinical decision making

Feeling unprepared to meet the challenges of the workplace

Deficits in clinical knowledge

5. Specific situations

Lack of confidence when dealing with acutely ill patients, emergency situations, and end-of-life scenarios

6. Stress management

Unfamiliarity with stress management techniques

Lack of social support

From Theisen, J., & Sandau, K. (2013). Competency of new graduate nurses: A review of their weaknesses and strategies for success. Journal of Continuing Education in Nursing, 44(9), 406–414. doi:



What is your greatest concern about your transition? Is it personal or work transitions because you are a student nurse, or is it your transition from school to the practice setting?

The role-transition process that occurs on entry into nursing school and the process from student to graduate nurse do not take place automatically. Having the optimal experience during role transition requires a great deal of attention, planning, and determination on your part. How you perceive and handle the transition will determine how well you progress through the process. It is important that you keep a positive attitude. The challenges and rewards of clinicals, tests, and work situations will cause your emotions to go up and down, but that is okay. It is expected, and you will be able to deal with it effectively. It is important that you keep a positive attitude. The wide range of emotions experienced during the transition process can often affect your emotional and physical well-being; check out the discussion of self-care strategies in Chapter 2.

So, let’s get started. Reality shock is often one of the first hurdles of transition to conquer in your new role as a graduate nurse or registered nurse (RN or Real Nurse icon).

Reality Shock

What Is Reality Shock?

Reality shock is a term often used to describe the reaction experienced when one moves into the workforce after several years of educational preparation. The recent graduate is caught in the situation of moving from a familiar, comfortable educational environment into a new role in the workforce in which the expectations are not clearly defined or may not even be realistic. For example, as a student you were taught to consider the patient in a holistic framework, but in practice you often do not have the time to consider the psychosocial or teaching needs of the patient, even though they must be attended to and documented.

The recent graduate in the workplace is expected to be a capable, competent nurse. That sounds fine. However, sometimes there is a hidden expectation that graduate nurses should function as though they have 5 years of nursing experience. Time management skills, along with the increasing acuity level of patients, are common problems for the new graduate. This situation may leave you with feelings of powerlessness, depression, and insecurity because of an apparent lack of effectiveness in the work environment. There are positive ways to deal with the problems. You are not alone! Reality shock is not unique to nursing. It is present in many professions as graduates move from the world of academia to the world of work and begin to adjust to the expectations and values of the workforce.


icon RESEARCH FOR BEST PRACTICE BOX 1.1Role Transition: Think Like a Nurse

Practice Issue

Students report that when they first entered their nursing courses they were unaware of the complexity of thinking and problem solving that occurs in the clinical setting. They often are unable to “think on their feet” and change a planned way of doing something based on what is happening with a specific patient at any given moment. Research supports the finding that the beginning nursing graduate continues to have difficulty making clinical judgments (i.e., thinking like a nurse). Graduates with baccalaureate degrees in nursing were interviewed three times in 9 months to determine their perceptions of how they learned to think like nurses (Tanner, 2006). In a later simulation study by Ashley and Stamp (2014), thinking like a nurse was one of the major themes that emerged when comparing sophomore and junior students. During simulation, the sophomore student approached the clinical scenario more as a layperson than as a professional with specialized knowledge, which was exhibited by little preplanning and the expectation that the clinical problem would be self-evident and would require nothing more than common sense to achieve an outcome.

Implications for Nursing Practice

Clinical Judgments—Thinking Like a Nurse

• Nursing students and new graduates are often unaware of the level of responsibility required of nurses and lack confidence in their ability to make clinical judgments.

• The process of learning to think like a nurse is characterized by building confidence, accepting responsibility, adapting to changing relations with others, and thinking more critically.

• Multiple clinical experiences, support from faculty and experienced nurses, and sharing experiences with peers were critical in the transition from student nurse to beginning practitioner.

• Nursing education must assist nursing students to engage with patients and act on a responsible vision for excellent care of those patients and with a deep concern for the patients’ and families’ well-being. Clinical reasoning must arise from this engaged, concerned stance.

Considering This Information

What types of resources will you utilize as a nursing student to improve your clinical reasoning skills? What characteristics have you observed in staff members who effectively think like a nurse”? How can you begin to incorporate these aspects into your practice as a new graduate nurse?


Ashley J, Stamp K. Learning to think like a nurse: The development of clinical judgment in nursing students. Journal of Nursing Education. 2014;53(9):519–525.

Etheridge S.A. Learning to think like a nurse: Stories from new nurse graduates. Journal of Continuing Education in Nursing. 2007;38(1):24–30.

Tanner C.A. Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Continuing Education in Nursing. 2006;45(6).

What Are the Phases of Reality Shock?

Kramer (1974) described the phases of reality shock as they apply to nursing (Table 1.1). Although she identified this process in 1974, these phases remain the basis for understanding the implications of reality shock and successfully progressing through the process. In our current world of nursing, we are still dealing with this same process. Adjustments begin to take place as the graduate nurse adapts to the reality of the practice of nursing. The first phase of adjustment is the honeymoon phase (Fig. 1.1). The recent graduate is thrilled with completing school and accepting a first job. Life is a “bed of roses” because everyone knows nursing school is much harder than nursing practice. There are no more concept care maps to create, no more nursing care plans to write, and no more burning the midnight oil for the next day’s examination. No one is watching over your shoulder while you insert a catheter or administer an intravenous medication. You are not a “student” anymore; now you are a nurse! During this exciting phase, your perception of the situation may feel unreal and distorted, and you may not be able to understand the overall picture.


Phases of Reality Shock

Honeymoon Shock and Rejection Recovery

Sees the world of nursing looking quite rosy

Often fascinated with the thrill of “arriving” in the profession

Has excessive mistrust

Experiences increased concern over minor pains and illness

Experiences decrease in energy and feels excessive fatigue

Feels like a failure and blames self for every mistakeBands together and depends on people who hold the same values

Has a hypercritical attitude

Feels moral outrage

Beginning to have sense of humor (first sign)

Decrease in tension

Increase in ability to be objective


FIG. 1.1 Reality shock. The honeymoon’s over.


Honeymoon Phase

I just can’t believe how wonderful everything is! Imagine getting a paycheck—money, at last! It’s all great. Really, it is.

The honeymoon phase is frequently short-lived as the graduate begins to identify the conflicts between the way she or he was taught and the reality of what is done. Every graduate nurse will have a unique way of coping with the situations; however, some common responses have been identified. The graduate may cope with this conflict by withdrawing or rejecting the values learned during nursing school. This may mark the end of the honeymoon phase of transition. The phrase “going native” was used by Kramer and Schmalenberg (1977) to describe recent graduates as they begin to cope and identify with the reality of the situation by rejecting the values from nursing school and beginning to function as everyone else does.


Shock And Rejection Phase

Mary was assigned 10 patients for the morning. There were numerous medications to be administered. It was difficult to carry all of the medication administration records to each room for patient identification. Because she “knew the patients” and because the other experienced nurses did not check identification, she decided she no longer needed to check a patient’s identification before administering medication. Later in the day, she gave insulin to Mrs. James, a patient she “knew”; unfortunately, the insulin was for Mrs. Phillips, another patient she “knew.”

With experiences such as this during transition, graduates may feel as though they have failed and begin to blame themselves for every mistake. They may also experience moral outrage at having been put in such a position. When the bad days begin to outnumber the good days, the graduate nurse may experience frustration, fatigue, and anger and may consequently develop a hypercritical attitude toward nursing. Some graduates become very disillusioned and drop out of nursing altogether. This is the period of shock and rejection.


I had just completed orientation in the hospital where I had wanted to work since I started nursing school. I immediately discovered that the care there was so bad that I did not want to be a part of it. At night, I went home very frustrated that the care I had given was not as I was taught to do it. I cried every night and hated to go to work in the morning. I did not like anyone with whom I was working. My stomach hurt, my head throbbed, and I had difficulty sleeping. It was hard not to work a double shift because I was worried about who would take care of those patients if I was not there.

A successfully managed transition period begins when the graduate nurse is able to evaluate the work situation objectively and predict the actions and reactions of the staff effectively. Prioritization, conflict management, time management, and support groups (peers, preceptors, and mentors) can make a significant difference in promoting a successfully managed transition period.

Nurturing the ability to see humor in a situation may be the first step. As the graduate begins to laugh at some of the situations encountered, the tension decreases and the perception increases. It is during this critical period of recovery that conflict resolution occurs. If this resolution occurs in a positive manner, it enables the graduate nurse to grow more fully as a person. This growth also enables the graduate to meet the work expectations to a greater degree and to see that she or he has the capacity to change a situation. If the conflict is resolved in a less positive manner, however, the graduate’s potential to learn and grow is limited.

Kramer (1974) described four groups of graduate nurses and the steps they took to resolve reality shock. The graduates who were considered to be most successful at adaptation were those who “made a lot of waves” within both their job setting and their professional organizations. Accordingly, they were not content with the present state of nursing but worked to effect a better system. This group of graduates was able to take worthwhile values learned during school and integrate them into the work setting. Often they returned to school—but not too quickly. Since Kramer’s original work, students are now encouraged to go back to school fairly quickly, especially with the emphasis from the IOM report of encouraging more advanced degrees in nursing.


Recovery Phase

I am really glad that I became a nurse. Sure, there are plenty of hassles, but the opportunities are there. Now that I am more confident of my skills, I am willing to take risks to improve patient care. Just last week my head nurse, who often says jokingly, “You’re a thorn in my side,” appointed me to the Nursing Standards Committee. I feel really good about this recognition.

Only gold members can continue reading. Log In or Register to continue

Apr 20, 2017 | Posted by in NURSING | Comments Off on Role Transitions
Premium Wordpress Themes by UFO Themes