The nursing profession has changed over the years, newly qualified nurse’s (NQN) have a professional role to uphold making it a very stressful transition, a poor experience during this transition period can delay a nurses full potential or leave them overwhelmed and ready to leave the profession altogether (Edwards et al., 2015).

This essay will firstly give an overview of the professional role of the nurse before going over what is known as the shock transition stage, an area many studies claim to be the initial stage of role adaption, discussing the stress and anxiety NQN come across. It will then go onto analyse different studies looking at accountability and delegation which are known to be some of the factors contributing to the stressful transition during this stage. Before finally discussing the varying strategies that have been put in place to support a smoother transition for the NQN to adapt and learn in their new role.

Historically, students of nursing were taught through an apprenticeship model that was developed in the late 1800s by Florence Nightingale. This model enabled the nurse to learn on the job, along with vital requirements for gaining competence in nursing practice. Florence worked ahead of her time, evolving the health care culture by creating and shaping our relevant, emerging nursing practice. Florence was a role model in her time changing the history of the healthcare system by thinking outside her domain (Beck, 2010).

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However, changing times meant a radical change to the way nurses were trained, Project 2000 was the start of a diploma style career which turned out very successful in increasing the nursing status (Glen, 2009). This paper shows how education moved away from the apprenticeship style in favour of an academic profession aimed to introduce a more critical, evidence based, professional nurse, building the gap between academic preparation and the clinical practice.

This brings with it far more accountability and responsibility for the professional role of the nurse, requiring a high level of professional proficiency at all times. The Nursing and Midwifery Council (NMC) is a professional body which regulates the professional standards of nurses and midwives. Nursing staff are bound by this code which ensures good practice, stating all nurses should be competent, confident and knowledgeable. The professional role of the nurse has certainly got more demanding as it has developed over the years into an academic profession.

Finishing university and starting a new job as an NQN can be a very exciting and daunting time. It is the beginning of what most students will see as a fruitful and rewarding career, it can, however, also be a stressful and challenging time as the transition takes place.

With stress being a major factor in the transition to NQN it is not surprising that there are a number of similarities between Edwards et al., (2015)who claims stress continues to pose difficulties for the NQN, this evidence is then backed up by Suresh, Matthews and Coyne, (2012) who state there still remains a cause for concern in the clinical environment, furthermore Suresh, Matthews and Coyne, (2012) presents a conflict with hierarchy and excessive workload to be just some of the issues regarding stress on nurses who are in transition.

There are however varying points of view put forward claiming different factors contributing to the main causes of stress in Feng and Tsai, (2012) the factors are regarding clashes between professionals and patient orientated care being the main points as a pose to  Halpin, Terry and Curzio, (2017) describes this stressful phase as the shock transition and is not confined to the UK but transcends international boundaries. This evidence is backed up by both Kinghorn et al., (2017) and Duchscher, (2009) claiming transition shock is experienced by the NQN as they find themselves working in situations, they neither experienced or prepared for, thus causing stress and anxiety.

Duchscher, (2009) also goes on to say, part of this issue arises when the support from university is no longer immediately available. With no immediate access to previous educators or peers to provide council or emotional support nurses are left feeling isolated and struggle with self -doubt in the transition period.

However, Kinghorn et al., (2017) claims the main fears for an NQN seem to be more based on evidence that when they are being exposed to clinical incompetence this in turn causes anxiety for the safety of their patient and additionally the responsibility and accountably the NQN now holds. Indeed Kinghorn et al., (2017) suggest that While it is clear the reality shock and emotional stress in transition can be a difficult time with many different factors, there are ways in which it can be managed with a formal and informal support system.

This is perhaps addressed by Tapping, Muir and Marks-Maran, (2013) who discusses the benefits preceptorship can offer, i.e. helping with reduction in stress and anxiety, which can help improve confidence and competence in the first stages of transition. conversely Whitehead et al., (2016) claims preceptorship can build on confidence and this paper also discusses the issues behind the preceptor scheme along with more up to date evidence alongside Irwin, Bliss and Poole, (2018) research suggesting it is only as good as the preceptorship trainer.

Perhaps, as lack of structure and support can lead to development issues with the NQN. These papers claim preceptors need to be highly trained individuals with vast experiences to benefit the NQN’s in their role, giving them the experience and skills necessary to thrive in their clinical area, with no fear to patient safety whilst they are being supported.

Accountability is a fundamental component of healthcare practice making it a very stressful factor involved in the NQN transition period. Scrivener, Hand and Hooper, (2011) claim nurses are given responsibly at a very early stage, answering to their own judgements and actions at all times, this can be a very daunting experience for the NQN. Carrying out these tasks in a manner that is acceptable to patients and their families.

Can indeed be very stressful, whilst always trying to remember to meet the requirements of the law and professional bodies.
After three years training the nurse will be expected to have the requirements and skills necessary of what it means to be a confident and responsible nurse. Additionally, they will also need to understand what accountability means in their new workplace all of which needs to be backed up by evidence-based practice with the focus of critical thinking and proven outcomes.

This consolidates what nurses have learned in the classroom and what they read in nursing literature. There is also research, it helps the nurse to critically evaluate the latest evidence and technology to determine how this may be applied in a clinical setting whilst conforming with nursing standards (Quality and Safety | Evidence based practice | Royal College of Nursing, 2019).This gives the nurse guidance and evidence to make sure they are making a commitment never to become a nurse who tolerates bad practice (Varney, 2013).

The NQN must understand what to do if they witness bad practice and when they should use the correct protocol put in place if they should see something they are unsure is correct, this may be having a courageous conversation with another member of the multidisciplinary team involved or informing a senior manager if the matter needs to be taken any further until it is addressed (Hole, 2018). However, studies reveal NQN are often to scared to speak up for fear of not fitting in to their new environment or having the confidence in their own ability to know what is right or wrong (Morrow, 2009).

Even as an NQN they should have the confidence to be able to report any issues they feel are not right at the time to avoid problems that may occur regarding patient safety within the care setting. The Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, (2013) shows the devastating consequences should the nurse choose to look the other way or not report any bad practice within their setting. This report also shows the need for NQN’s to make sure they are accountable for their own training and keep up to date with all new evidence-based practice to be able to understand when situations are not right and need addressing in a competent manner.

Ayako Okuyama, (2014) shows how hesitancy to speak up can be an important contributing factor to errors or adverse events. Health care professionals voicing there concerns can be a good opportunity to stop this from happening, but they must have the confidence within their team to be able to do this without any repercussions, it should be seen as helping the team, by developing an open and honest setting that can be challenged at all times without fear.

Feng and Tsai, (2012) and (Hunter and Cook, 2018) discusses the point of socialising in the nursing practice, stating the professional socialisation process is a concept of feeling ‘part of the team, for the NQN. Nurses must be aware of this socialisation process as this may change in clinical practice adopting a less than ideal way of working because fitting into a team takes priority. This argues the point that NQN may then not report bad practice for fear of ostracisation.

However, (Hunter and Cook, 2018) raises awareness of positive clinical practice. There are challenges during this major transitional time. Where there are inconsistencies between ideal care and actual care delivery, powerful role models within the care setting should be able to inspire NQN to be able to speak up in areas of bad practice as their new role means they are professionally responsible for the care of their patient at all times.

If the nurse is unsure of the role, they have taken on in transition it may be best to speak up with confidence to get the support needed to help them make informed decisions in their transition period. The NMC, (2015) gives advice on making the correct decision in difficult patient-care situations. Knowing that poor support can have a devasting effect on patient care, Nurses must always be aware of the damage this can cause and deal with it immediately in the correct manner (Kumaran and Carney, 2015).

Speaking up in difficult situations can help improve patient care, however, as already explained this can be difficult in a new role and is is not always easy, a good strategy to help overcome this issue would be reflection. Good reflective practice can give the opportunity for positive learning and open communication with team members and hierarchy.

The focus has often been on reflection as an academic, saved for the classroom environment however, reflection is at the heart of practice, with all nurses having to demonstrate that they are undertaking this exercise with good knowledge and understanding of the process. When used correctly, reflection can be a valuable lifelong learning tool, which is useful for promoting personal development, and optimizing the care provided for patients along with a way to communicate any issues you may have within the team (Myatt, 2017).

Reflection is a very important skill students are taught in university, it is often used to help establish clinical improvements, enabling nurses to explore how a clinical episode felt and what it signified to them, and what if anything could be done to make the situation any better( Nursing times, 2012).

Reflection has been widely accepted to help with knowledge and understanding through evidence based practice, putting patient centered, holistic care at the forefront of how nurses should be thinking, giving the NQN a guide to work within and a journey to be able to reflect on in the future with a better understanding of their role which will help with their confidence and competence throughout their journey (Fowler, 2014).

Delegation is another factor causing stress amongst the NQN. A requirement for nurse training states the NQN’s should be able to delegate duties to others as appropriate, ensuring that they are prevised and monitored, however studies suggest there is a lack of academic preparation to perform this skill. Josephsen, (2013) implies that delegation is an area where newly qualified staff experience huge difficulties claiming students often feel unprepared to delegate upon registration, either because of lack of confidence or understanding within the role.

Delegation is no easy subject, The NMC, (2015) writes that delegation is the process by which responsibility and authority for performing a task is transferred to another individual who accepts that authority and responsibility. Although the delegator remains accountable for the task, the delegate is also accountable to the delegator for the responsibilities assumed.

Sprinks, (2015) notes that nurses must only delegate tasks and duties that are within the other persons scope of competence, making sure they fully understand the instructions given. Delegation can help to develop or enhance skills and promote teamwork which in turn improves productivity if done right (. Sollivan.E. J et al, 2009). Magnusson et al., (2017) discusses the many different approaches to delegation by NQNs explaining the most common style of delegation identified in the study was the do-it-all nurse.

The findings indicated that the do- it -all nurse actively avoids delegation in the beginning and opts to do the work themselves due to lack of confidence in their role and understanding of how to delegate. Halpin, (2016) discusses the effect this can have on the nurses workload managing multiple role demands within the time limit of their shift causing stress and anxiety.

Hasson, McKenna and Keeney, (2013) is another study claiming this area is an underdeveloped skill, suggesting that there is a lack of academic preparation for this role. However, he also goes on to indicate there are other issues facing the NQN when it comes to delegating. Claiming blurred lines between the health care professional and the nurse’s role as another contributing factor to delegation, suggesting a lack of clarity in healthcare assistants roles can cause confusion during delegation of tasks.

NQN need to be able to exercise personal authority to become a more competent nurse, being assertive will help to enhance nurses development in delegation along with confidence within the job as they become more competent in their own role. Over time the NQN should be able to delegate with competence and understanding (Magnusson et al., 2017).

Delegation is a skill to be worked on within the clinical setting, there are many ways of doing this, one way to get up to date training and knowledge on this situation would be to participate in the flying start program a strategy put in place by the government to help all NQN adapt to their role and learn new skills along the way.

This strategy gives the NQN a way to map their progress against the knowledge and skills framework. This framework is in place to support personal development and career progression within the national health service. Flying start consists of 10 units, each containing clear aims and objectives to help the NQN adjust to their new responsibilities within their role.

Giving structured support in the transition period, however, Schneider and Good, (2018) points out the biggest barrier to learning in the hospital is time, while protected time is given for the flying start programme, it is unrealistic to think that this will always be available in an ever changing environment. It is, in the long run up to the nurse to make sure she is fully competent and up to date with training as part of her professional standards.

This will give them the skills to help them take responsibility for the care they are providing learning from other experienced nurses along the way, understanding how the hierarchy and delegation process works to get this right (\”Are newly qualified nurses prepared for practice?”, 2011).

In conclusion it is clear the role of the nurse has evolved over the years, giving nurses a far more professional status, however with this comes accountability, meaning the transition from student nurse to NQN has become far more stressful. It has been widely recognised that this transition causes shock within the NQN setting. However, there are strategies being put in place to try and make this transition a little smoother.

Flying start gives the NQN a chance to enhance their skills and knowledge helping them in their future career, while reflection has given the NQN a way to talk over situations they may be unsure of in a safe environment giving examples on how to improve for the future and preceptorship gives guidance when its needed to give the NQN the confidence to know the patient is in a safe person centred, environment that they can trust.

Safe practice in the working environment is essential to the NQN transition as this essay shows bad practice can have devasting consequences. The NQN will have to make sure they are confident within their role keeping up to date with all training so they can make sure they understand the latest evidence eased practice to comply with the nursing standards.

Although these studies have no clarity as to what would be best to prepare the NQN for their professional role it is clear they may need to call different strategies within their career to give the best possible care making sure they always lead by example and follow the codes of conduct, to provide person centred holistic care in a safe working environment.