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Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 214-220

New graduate nurses' transition: Role of lack of experience and knowledge as challenging factors

Department of Community, Psychiatric and Mental Health Nursing, College of Nursing, King Saud University, Riyadh, Kingdom of Saudi Arabia

Date of Submission01-Jun-2020
Date of Decision27-Jun-2020
Date of Acceptance30-Jul-2020
Date of Web Publication07-Nov-2020

Correspondence Address:
Omar Ghazi Baker
College of Nursing, King Saud University, Riyadh
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjhs.sjhs_88_20

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Context: Lack of experience and practical knowledge makes it difficult to deal with the issues related to health-care practices. This acts as a threat to the learner's theoretical ability. Aims: The study aims to identify the challenges and the associated factors which limit the knowledge acquisition of new nurse graduates in Saudi Arabia. Settings and Design: A cross-sectional study design was used in which a sample of 95 individuals was recruited from public hospitals in Al-Baha region. Subjects and Methods: A primary survey approach was used to collect data from nurses using close-ended questionnaire. Statistical Analysis Used: IBM SPSS (Statistical Tool for Social Sciences) version 20.0 was used to conduct the statistical analysis. Results: The challenges include role expectations, lack of confidence, workload, fear, and orientation issues, while other factors such as physical environment, responsibility, support, and professional development create a sense of dissatisfaction among nursing professionals. New graduate nurses are infrequently scheduled in situations where they cannot feel confident in dealing with clinical cases. Conclusions: The study concluded that transition is the major issue with respect to difficulties faced by nurses in the health-care environment.

Keywords: Environment, health care, knowledge, nurses

How to cite this article:
Baker OG. New graduate nurses' transition: Role of lack of experience and knowledge as challenging factors. Saudi J Health Sci 2020;9:214-20

How to cite this URL:
Baker OG. New graduate nurses' transition: Role of lack of experience and knowledge as challenging factors. Saudi J Health Sci [serial online] 2020 [cited 2023 Jun 4];9:214-20. Available from: https://www.saudijhealthsci.org/text.asp?2020/9/3/214/300297

  Introduction Top

Nurses constitute an integral part of the health-care organization globally.[1] Though frequent changes in the health care environment require from nurses to have an updated level of knowledge, but newly graduated nurses, when joining this progressively complex health care environment, still need to have sufficient learning experiences to meet the expectations for such demanding practice.[2] Its significance is manifested on account of increased prevalence of the chronic disease, lengthy hospital stays, and hospitalization with acute disease. Potgieter[3] noted that an increased ratio of patients, lack of health-care facilities, and the absence of nurse educators contribute to the inadequate knowledge of the graduate nurses.

Saudi Arabian Health Care System relies mainly on the expatriates from more than 40 countries who constitute approximately 80% of the total workforce needed in the view of exponential growth of population.[4] According to the King Faisal Specialist Hospital and Research Centre,[5] Saudi nurses comprise 2% of the total workforce working in different hospitals. Precisely, the literature shows that newly qualified nurses fail to develop an adequate understanding that affects their care delivery.[6] The changing demand of the health-care environment requires from health-care nurses to be increasingly competent and technologically sound. Despite these, newly graduate nurses fail to show adequate understanding and knowledge. Van Graan et al.[2] state that knowledge about computer processes and prescribed techniques is not enough to solve the patient's problem. It is due to the lack of students' competence to detect challenges and problems which adversely impact their learning in the health-care environment.[7]

Several studies argue that students' lack of exposure to the actual health-care learning environment has accelerated dropout rates.[8],[9] This is due to the challenges they encounter while going through the transition from an academic setting to an actual delivery setting.[10] The inability to devise effective and prompt decisions leads to anxiety. Yazdannik et al.[11] state that nurses face these challenges once they enter the actual health-care environment. This includes inadequate practice of knowledge which serves as a source of stress and anxiety among the new graduate nurses.[9],[12] AAl[13] highlighted the challenges that include insufficient knowledge of nurses, the gap in theory and practice, contradictory objective in relation to education and expectations as well as substandard feedback and supervision.

Alsaqri[14] also stated that the anxiety and stress among the students can be subsided with experience and support which builds their confidence in clinical practices, as all these factors thwart the students learning ability. Ebrahimi et al.[15] highlight that communication and an appropriate clinical environment can help combat these factors. Kehrhahn[16] writes that these must be catered at the preliminary stage when the students are inducted and given orientation. This effective orientation process allows the new graduate nurses to quickly become exposed to the culture and the protocols followed at the hospital.[17] Olson-Sitki et al.[18] have reported the substantial impact of the structured orientation program on the new graduate nurses in terms of their skill, retention, and commitment assisting in overcoming the knowledge gap.

According to the global statistics, developing countries like Saudi Arabia are reported to have high turnover rates and shortage of qualified nurses with frequent repercussions on the quality of health-care services.[19],[20] Furthermore, the heavy reliance of the Saudi health-care sector on the expatriate nurses emphasizes developing their competence for adequately responding to the changed working environment as it constitutes 60% of the overall nurse population.[21],[22] Alharbi and Alhosis[23] have also highlighted that the Saudi nursing sector experiences various difficulties in responding to the changing health-care environment.

Furthermore, an anticipated 25% of new graduate nurses experience issues related to problem-solving and critical reasoning skills which lead to inadequate patient care.[24] Education, experience, and personal factors, which include general career expectations, economics, and parental relationships, contribute to acclimatize new graduate nurses' ability to professional practice.[16] It has been notified that the empowerment of new graduate nurses is important as the knowledge of new graduate nurses allows them to enter the program.[25] This also helps in contributing to the Saudization concept (i.e., increase in the Saudi citizens' employment) as most of the health-care providers are expatriates. Improved retention and professional satisfaction are associated to reduce reality shock and improve empowerment. Nursing faculty should educate students who are able to face the challenges of professional practice as expected by the members of the current health-care industry.[26] Considering the points and the fact that no study has been performed on the Al-Baha region, Saudi Arabia, the study aims to identify the challenges and the associated factors which limit the knowledge acquisition of new nurse graduates in Saudi Arabia. Thus, it is presumed that the results of the study will assist in understanding the challenges that were faced at the initial stages. Further, it will also assist in devising improved programs for making the student to staff transition easy and successful. The research questions addressed in this study are as follows:

  • What are the challenges and associated factors that limit the knowledge and experience acquisition of the new graduate nurses in Saudi Arabia?
  • How could student and staff interaction be made easy and successful?

  Subjects and Methods Top

The study adopted a cross-sectional research design. A quantitative approach was used as it assists in gathering data effectively.[27] Furthermore, this approach allows eradicating all the possible biases due to the limited involvement of the researcher with the research sample.[28]

In this study, a questionnaire-based survey was used as a tool to collect data. The survey was divided into two parts; the first part was about demographic details of the participants and the second part was related to the associated challenges, experience, and knowledge.

The second survey tool used in this study was the Casey-Fink Graduate Nurse Experience Survey (NLRN). This tool is available for the public use and it was obtained from the author's website after completing a questionnaire. The tool was developed by Kathy Casey and Regina Fink in 1999 to measure NLRN comfort with skills over time. It has a Cronbach coefficient alpha (α) of 0.89. Validity testing was originally done using an expert panel of educators and nursing directors.[29] Casey et al.[29] reported that the authors described the item categorization and individual reliability measured by Cronbach's α for each of the following categories:

  • Support (α = 0.90) – items 19, 9, 6, 7, 18, 10, 4, 13, and 23
  • Organizing/prioritizing (α = 0.79) – items 16, 5, 8, 12, and 17
  • Stress (α = 0.71) – items 24 and 25
  • Communication/leadership (α = 0.75) – items 1, 3, 15, 14, 11, and 2
  • Professional satisfaction (α = 0.83) – items 20, 21, and 22.

The answers were obtained using a Likert scale response ranging from “1” for “very unlikely” to “5” for “very likely.” Intent to stay or leave the current employer or position was measured similarly by other nurse researchers including Brewer et al.[30]

The survey asked the participants about the impact of experience and knowledge and its supplementing factors: work environment, relationship with colleagues, patient safety, stress, expectations, communication, and satisfaction. The rationale behind the selection of the instrument was based on its gathering of data effectively and efficiently.

Content validity was established by review and assessment of expert nurse educators and directors working in both academic and private hospitals. The content of this tool was obtained from a substantial and inclusive literature review. This tool was recognized as discriminating and differentiating between nurses with varied and diverse amounts of experience during the first year of practice.[28]

Two weeks' time was given to the participants for filling in the questionnaires and returning it to the nursing directors in the targeted health-care setting and the questionnaires were then analyzed by the researcher.

Institutional ethical approval was obtained from the Institutional Review Board at King Saud University for performing the study. Approval of research project number was “E-17–2227.” Later, the researcher contacted the human resource (HR) department of the hospital. An e-mail with the details concerning the study such as its objective, scope, and the requirement was sent to the HR departments of the hospitals. Upon receiving approval, the survey was carried out. The survey was conducted for 6 weeks in which the questionnaires were distributed during the lunch break of the nurses in the presence of the researcher. This enabled the researcher to provide rapid response to the nurses' queries. Prior to the survey, the participants were asked to describe the study to highlight their contribution. They were also assured of data confidentiality and anonymity. In addition to that, written consent was also acquired from the participants.

For the data analysis, the study used the IBM SPSS Statistics for Windows, Version 20.0 (IBM SPSS, V 20.0, 2011, Armonk, NY: IBM Corp., United State of America) software. Initially, the items of the questionnaire were analyzed by descriptive and inferential statistics. It is noteworthy to mention that it is not possible to apply Chi-square for Casey-Fink Graduate Nurse Experience Survey and number of preceptors because the data are continuous; however, issues faced in transition period, support factors, and satisfying and unsatisfying factors among nurses have been calculated using Chi-square. Hence, Chi-square test was used for determining the impact of lack of experience and knowledge as challenging factors in a health-care setting, and linear regression analysis was used to assess the relationship between the number of preceptors and NLRN factors. The significance value was determined at 0.05.

  Results Top

The study included 95 new graduate nurses with a mean age of 27.84 years. [Table 1] shows the gender distribution of the recruited nurses and reveals that 50.5% were male and 49.5% were female nurses.
Table 1: Demographic profile of the nurses

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The distribution of factors related to the difficulties experienced was related to the transition of nurses from students to professional health workers. Chi-square was used to calculate issues faced in the transition period. The challenges faced by these individuals included role expectations (25.5%), lack of confidence (31.9%), workload (53.2%), fear (24.5%), and orientation issues (16%) [Table 2]. These results were also supported by the achieved P value (<0.05).
Table 2: Issues faces in the transition period by the nurses (n=95)

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Support factors have been calculated using Chi-square. The nurses suggested that they feel more supported or integrated into the unit if they are provided with improved orientation (40%), increased support (50.5%), unit socialization (33.7%), and improved work environment (34.7%) [Table 3]. This indicates that orientation programs and supportive interventions should be implemented. The achieved P value corroborated these results.
Table 3: Support factors among the nurses

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Satisfying and unsatisfying factors among nurses have been calculated using Chi-square.

The nurses reported that peer support (61.1%), patients and families (42.1%), ongoing learning (18.9%), professional nursing role (32.6%), and positive work environment (34.7%) enhanced their satisfaction toward their work in the working environment. On the contrary, the factors such as nursing work environment (33.7%), system (58.7%), interpersonal relationship (31.5%), and orientation (12%) were expressed as the factors that provided the least satisfaction in their working environment [Table 4]. These results were also supported by the achieved P value (<0.05).
Table 4: Satisfying and unsatisfying factors among the nurses

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Linear regression analysis was used to assess the relationship between the number of preceptors and NLRN factors [Table 5]. The findings showed that there was no significant relationship between support, patient safety, communication/leadership, professional satisfaction, and job satisfaction on number of preceptors (P > 0.05).
Table 5: Relationship between different factors of Casey-Fink Graduate Nurse Experience Survey and number of preceptors

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  Discussion Top

The study aimed to identify the challenges and associated factors that restrict the knowledge acquisition of new nurse graduates in Saudi Arabia. The study outcomes report that socialization, improved work environment, increased support, and improved orientation help in improving understanding and knowledge of nurses. Earlier studies have also revealed similar findings which show that support enables better understanding and delivery of improved quality services.[31],[32]

The findings also have indicated that supported or integrated activities within the unit are unit socialization, improved work environment, increased support, and improved orientation. The nurses were satisfied with their working environment which was based on peer support, ongoing learning, professional nursing role, patients and families, and a positive working atmosphere. On the other hand, the factors which contributed to the least satisfaction among new graduate nurses in their working environment were found to be working system, interpersonal relationship, orientation, and nursing work environment. The study of Jeffery et al.[33] also supports the above findings, depicting that improved orientation helps in a better understanding of the new graduate nurses. Another study of Tripathy et al.[34] contradicted the findings while stating that interpersonal relations are effective for better understanding in the health-care sector.

The current study findings reported that about half of the sample was experiencing stress in their life. Khamisa et al.[35] stated that job performance, personal relationships, living situations, and finances should be considered for reducing the stress level in the student. One of the previous studies supported the aforementioned factors and indicated that intention to leave was associated with dissatisfaction.[36]

A strong foundation establishes that growth in the nursing workforce and effective maintenance is linked to reducing shortage of nurses, integration of health reforms, and recessions of new graduate nurses.[37],[38] The transition of new graduate nurses cannot be completed from advanced beginner to competent practitioner if they fail to adapt. Kramer[39] gave the reason that this is due to the reality shock, which they experience upon their transition. Ineffective responses in nursing are consistently exhibited through increasing costs and high attrition rates of new graduate orientation.[40] In contrast, good support from peers helps these new graduate nurses to cope with the complex situation.[41] Workload and skill-mix issues are among the most likely factors that restrict new graduate nurses from feeling confident. Lamadah and Sayed[24] reported that some new graduate nurses failed to adapt to such situations due to the paucity of clinical support. Another study reported that initial effective orientation facilitates and develops an affirmative experience when supplemented with a supportive work environment.[42] This involves developing understanding in coworkers and managers along with the alignment of the process, mission, vision, and values. Besides, outlining and developing an understanding of organizational policies for the new graduate nurses aiming to accomplish patient safety and quality care also helps them deal with the challenges imposed by health-care environment.[25] Caputi and Kavanagh[43] further suggest that new graduate nurses must be promoted to think and reflect on different scenerios for developing their understanding.

Pineau Stam et al.[25] emphasized that new graduate nurses' integration in the health-care environment is promoted through their empowerment. The results of Olson-Sitki et al.[18] suggested that nurse residency programs help to overcome the challenges in implementing knowledge and skills in acute care settings.

These findings are supported by previous studies in which the significance of time is emphasized for improving the work environment for the new graduate nurses.[4],[9],[38],[44] Time is important for new graduate nurses to brainstorm and reflect on their daily activities. All new graduate nurses should observe what their daily achievements and their engagement in critical thinking and self-awareness.[44] New graduate nurses must be keen to share their experiences, reflect on their orientation, and discuss good and bad challenges with each other. According to Farrell et al.,[44] self-reflection and storytelling are curable factors for the new graduate nurses as stories will help the other new graduate nurses. These reflective groups can be scheduled within the orientation procedure at several intervals. Team and individual meetings also help provide support and aid in reflective practices. This practice not only ensures to recognize the new graduate nurse effectively but also offers an assessment time for evaluating the orientation progress. According to Henderson et al.,[45] the progress meetings should be scheduled during the workday and it should offer enough time for discussion.

The study has also listed several limitations that should be addressed for better generalizability. In the first place, the study included a sample of 95 newly graduate nurses, which might not provide enough reflection of the overall new nurse population. In the second place, the study was conducted in public hospitals in Al-Baha region with a hospital experience of 6 months to 2 years. Thereby, the data cannot reflect the population of huge urban hospitals. The survey questionnaire was another limitation as the use of interviews could have improved study results.

The findings of the study imply toward initiation of the collaborative practices for escalating the confidence level of the students. In this regard, efforts can be introduced at organizational and team levels such as training can be offered to the new graduate nurses, while responsibilities can be assigned to a selected team member. Furthermore, the organizational leaders can connect with the new graduate nurses to boost their confidence level. Besides it, opportunities can be provided for interprofessional collaboration which helps in enriching their knowledge base to facilitate in overcoming the possible challenges. A policy can be established that should emphasize on the rotation of the new graduate nurse within the clinical settings and on the responsibilities of expanding the knowledge horizon of new graduate nurses which amplifies their confidence level that is essential for independent individual performance.

The study has concluded that transition is the major issue with respect to the difficulties faced by nurses in the health-care environment. The major challenges faced by nurses in their working environment include role expectations, lack of confidence, workload, fear, and orientation issues. Factors that create a sense of dissatisfaction in the nurses include physical environment, responsibility, support, and professional development. It is possible to cater the challenges, highlighted in this study through enhanced support, orientation, and peer relationship that would help new graduate nurses in understanding the work environment. New graduate nurses are infrequently scheduled in situations where they lose their confidence to deal with clinical cases. Therefore, the present study recommends that transitional support programs are beneficial for supporting new graduate nurses. Educators, nurses, and nurse managers can better support new graduate nurses and promote their confidence and competence to practice by sharing their experiences and unachieved needs during their earlier years. New graduate nurses form a special group need uniform support by administrators, educators, and managers for assuring that they receive an objective-based orientation. Thereby, the inauguration of facility orientation will be a crucial step in the transition phase from student to nurse, which provides them job satisfaction, competence, and confidence. It is, therefore, crucial to guide new graduate nurses and to offer them learning opportunities. Hospital orientation programs are required to change the needs of new nurses in an ever-changing health-care environment.

Further research can undertake new graduate nurses to examine their need for a structured orientation and formalized period, based on the clinical area of nurses. Objectives will be required in the formalized orientation for transitioning in the orientation process. In addition, preceptor education is another key area that should be researched properly.

  Conclusion Top

New graduate nurses' transition period is regarded as an important part of adaptation to work environment, and new graduated nurses' experiences during transition have a pivotal effect on their decision to pursue nursing as a career, emphasizing the importance of equipping them with the necessary support, orientation and supervision.


The author is very thankful to all the associated personnel in any reference that contributed in/for the purpose of this research. The author further acknowledges Musaad Alghamdi who then as a graduate student helped and collaborated in executing the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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