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Nurse Education in Practice

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Doctorate Studies

Nurse practitioners’ experiences with role transition: Supporting the learning curve through preceptorship

Viktoriya Pleshkana,∗, Leslie Husseyb

a Loewenberg College of Nursing, University of Memphis, 4055 North Park Loop, Community Health Building, Memphis, TN, 38152, USA b School of Nursing, College of Health Professions, Walden University, 100 Washington Ave S. Suite 900, Minneapolis, MN, 55401, USA

1. Introduction

Registered nurse (RN) to nurse practitioner (NP) role transition is characterized by significant changes in nurses’ role, including increased levels of autonomy and new responsibilities of being a prescriber. The problem begins with the gap between NPs’ education and the level of skills required at the start of NP practice. To close the gap between education and practice, preceptorships have been used to support NPs’ clinical learning, both before and after graduation. However, pre- ceptorships used prior to graduation have not had major changes since the 1960s and preceptorships used after NPs graduate are scarce (AACN, 2015; Giddens et al., 2014; LeFlore and Thomas, 2016). Pre- ceptorships are essential for NPs’ clinical skill acquisition.

1.1. Background

NPs are RNs with advanced nursing education and clinical training who are licensed to diagnose and prescribe in the United States (Coombs, 2015). In recent years, the demand for NPs grew due to the shortage of primary care (PC) services (Giddens et al., 2014). The number of practicing NPs has increased by more than 100,000 since 2009 with the current total number of practicing NPs exceeding 234,000 (American Association of Nurse Practitioners [AANP], 2017a). To accommodate this increased need, the number of NP programs also proliferated to approximately 350 (AANP, 2017b). Because NPs obtain their skills through experiential learning, clinical education is the foundation of NP programs. However, the clinical training model has not had major changes in 45 years (AACN, 2015; Giddens et al., 2014; LeFlore and Thomas, 2016).

The RN to NP role transition has been identified as difficult and stressful (Brown and Olshansky, 1997; Flinter and Hart, 2016; Steiner et al., 2008). Though many other medical professions offer residencies to their new graduates, most NPs start practicing independently right after graduation (Hevesy et al., 2016). The ill-supported clinical edu- cation during school is followed by the lack of transition support after graduation (AACN, 2015; Brown and Olshansky, 1997; Donley et al., 2014; Flinter and Hart, 2016; Logan et al., 2015; Roberts et al., 2017;

Steiner et al., 2008; Webb et al., 2015). Employers expect newly graduated NPs to care for a wide range of complex patients. Novice NPs expressed concerns about the lack of training to perform procedures, such as suturing, fracture care, X-ray readings, etc. (Jones et al., 2015). Lack of clinical skills may have an impact on NPs’ transition to practice.

Preceptorship is fundamental to NPs’ experiential learning, both before and after graduation and vital for NPs’ successful transition to practice (Brown and Olshansky, 1997; Jones et al., 2015; Leggat et al., 2015; Wiseman, 2013); however, the literature on preceptorship and transition is scarce (Jarrell, 2016; Poronsky, 2012). Before graduation, NP students struggle with their preparedness for clinical experiences and with the availability of their preceptors and clinical sites. Many preceptors have expressed concern about students’ preparation level and questioned their preparation for practice (Roberts et al., 2017). The challenges of obtaining clinical sites and preceptors have been well documented (Drayton-Brooks et al., 2017). Further, preceptors are struggling to accommodate NP students’ learning needs without having their workload adjusted (Giddens et al., 2014; Keough et al., 2015; Poronsky, 2012). Though preceptorship is at the core of NP clinical education, it is in great need of restructuring and support.

Although many other medical professionals are being supported through well-structured clinical education and residency programs, formal NP preceptorship is uncommon after graduation (Wilkes and Feldman, 2017). With the lack of formal preceptorship to support no- vice NPs’ role transition after graduation, the major source of pre- ceptorship for NPs comes through a formal collaborative relationship with their assigned physicians (Jones et al., 2015). However, the MDs’ abilities to train may be limited. Medical and nursing paradigms differ significantly and yet, MDs are expected to guide NPs in their role transition. Physicians’ knowledge of NPs’ role and scope of practice is important for these professionals’ effective collaboration. However, MDs have little familiarity with NPs’ role, education, and training (Schadewaldt et al., 2013; Van der Biezen et al., 2017), which is the most common barrier to a successful NP and MD collaboration (Schadewaldt et al., 2013). Lack of formal preceptorships after the graduation contributes to NPs’ difficult transition to practice.

It is important to explore the current state of preceptorship support.

https://doi.org/10.1016/j.nepr.2019.102655 Received 17 October 2018; Received in revised form 27 October 2019; Accepted 6 November 2019

∗ Corresponding author. E-mail addresses: vyplshkn@memphis.edu (V. Pleshkan), leslie.hussey@mail.waldenu.edu (L. Hussey).

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Several studies were conducted about NPs’ role transition after gra- duation (Brown and Olshansky, 1997; Chappell, 2014; Flinter and Hart, 2016). Scholars confirmed that NPs’ role transition and preceptorship need support. However, how this transition process is currently sup- ported through preceptorship remains largely unknown. The problem is that NPs’ role transition is difficult and poorly supported through an outdated preceptorship model. Learning about the current state of preceptorship model may add insight into how it can be improved.

2. Theoretical foundation

The theoretical lens of this study consisted of the combination of two theories, Schlossberg’s transition theory, and Collins, Brown, and Holum’s Cognitive Apprenticeship Model (CAM). The concept of tran- sition was guided by transition theory, and the concept of preceptorship was guided by CAM.

3. Aim

The purpose of this study was to explore the NPs’ experiences with their role transition while in a preceptorship. Understanding how NPs transition to practice and how a preceptorship supports their transition may inform educators and employers on how to strengthen the transi- tion.

4. Method

4.1. Study design and approach

The nature of this study was qualitative. The approach to this qualitative inquiry was Van Manen’s (1990) hermeneutic phenomen- ology. When used together, the descriptive and interpretive approaches allow a deeper understanding of the participants’ experiences (Matua & Van Der Wal, 2015). Using phenomenology allowed for a description of participants’ experiences, while applying hermeneutics allowed ex- tracting the essence of participants’ lived experiences in a specific context (Van Manen, 1990). Hermeneutic phenomenology design as- sisted with obtaining and explaining descriptive data in a study specific context.

4.2. Sample

After receiving an Institutional Review Board Approval from the Walden University (Approval Number 01-16-18-0522648), a con- venience sample of 16 currently practicing NPs who had been employed as a NP for at least three months but no longer than five years and who had a current collaborative agreement with an MD, was recruited through the Greater Memphis Area Advanced Practice Nurses Association, social media sites, and snowballing.

4.3. Data collection

Sixteen participants were interviewed by the author using a seven question interview protocol. One face-to-face, three Skype, and 12 phone semi-structured interviews were conducted. The interview questions were based on an extensive review of literature and the transition and CAM theories described above. Each interview ranged from 37 to 95 min. Audio recordings were manually transcribed and transferred into the MAXQDA program.

4.4. Data analysis

All data were transcribed manually by the authors using the MAXQDA qualitative data analysis software. Data analysis was con- sistent with the chosen hermeneutic phenomenological design guided by Van Manen’s approach. Sixteen transcribed interviews were coded

using Van Manen’s analysis strategies. During the initial stages of open coding, transcripts were read several times. Field notes created during the transcription process were analyzed. Over 200 codes were derived and each was assigned a memo (code’s short description). Next, data were analyzed according to the two participants’ role transition stages (pre and post-graduation), clinical settings where their experience took place, participants’ relationships with their preceptors, and their reac- tions to their role transition experiences. Seven major themes were identified. MAXQDA analysis program assisted in proper data display and its easy retrieval.

4.5. Trustworthiness

To ensure data trustworthiness, data credibility, transferability, dependability, and confirmability were established. Clear, detailed de- scriptions, prolonged engagement with participants and data, rich data, and triangulation were ensured. Prolong engagement with participants was achieved by conducting interviews. Longer interviews allowed es- tablishing of trust between researcher and participant leading to a more comfortable discussion of the phenomenon by the participant. Triangulation in data collection was established through multiple data collection methods. Namely, to collect data, field notes and partici- pants’ descriptions were used.

4.6. Ethical considerations

All study participants were provided with the written information regarding the study purpose and research process. All participants re- ceived information about the study prior to and during the interviews. All participants were informed of the voluntary nature of their parti- cipation and ability to cancel at any time. All participants consented via e-mail and received an Amazon certificate of $10 dollars after the in- terview.

5. Results

In exploring participants’ experiences with their transition to prac- tice and preceptorship before and after the graduation, the following seven themes emerged from the data, (a) transition preparation and learning; (b) preceptorship during role transition and learning; (c) learning to care for complex patients; (d) learning in clinical environ- ment; (e) transitioning to a greater autonomy and new responsibilities; (f) embracing the role and identity confusion, and (g) transition reac- tions (Table 1).

5.1. Theme I: Transition preparation and learning

In this theme, participants’ preparation for clinical experiences pre and post-graduation was explored during their role transition. Prior to graduation except for the occasional “meet and greet” clinical or- ientation, there was no other preparatory work before the participants’ start of their clinical rotations. Participants were not aware of their preceptors’ expectations or work style until the start of their clinical rotations, “P5: I don’t feel like I understood what was going to be

Table 1 Themes.

Theme Number Theme Name

Theme I Transition preparation and learning Theme II Preceptorship during role transition and learning Theme III Learning to care for complex patients Theme IV Learning in clinical environment Theme V Transitioning to a greater autonomy and new responsibilities Theme VI Embracing the role and identity confusion Theme VII Transition reactions

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expected of me in clinical.” Immediately after graduation, many par- ticipants reported feeling unprepared to practice independently, “P2: You kind of just get thrown and figure it out.” Many reported lack of orientation for their clinical experiences while in school. Similarly, post-graduation, many reported lack of adequate onboarding process.

5.2. Theme II: Preceptorship during role transition and learning

The second theme contained the data related to the instructional strategies used to precept NPs pre and post-graduation. Before gra- duation, the most effective instructional strategy reported was “see one, do one,” in which the preceptor demonstrated the skill and then ob- served the student perform the skill, after which, the student performed more independently. However, such hands-on experiences were rare: “P16: the only procedure I really got to do in clinicals … doing a pelvic exam.” Preceptors’ teaching styles were reported to be inconsistent among various preceptors and clinical settings. Preceptors’ workload and lack of day to day feedback frequently prevented them from pro- viding participants with adequate instruction, “P12: … 40 patients a day, so I don’t know if they had time to sit down and explain a lot of stuff to me.” Case discussions and debriefings were frequently omitted from students’ learning experiences due to the time constrains.

After graduation, participants learned their NP role through self- teaching and asking questions, “P1: most of the things that I have learned and that I do it is because I looked it up and I researched it myself.” Though all participants had collaborative agreements with their MDs expecting them to mentor, many reported minimal to no help from their collaborators: “P14: … post-graduation I had collaborators on paper and … I did not have anyone to really break down my day to … I wish I may be had some support…” Being left alone to learn and master their new skills generated feelings of stress and fear.

Both before and after graduation, participants reported their pre- ceptors’ lack of time to teach them, which affected participants’ ability to learn their clinical skills. Overall, dependence on their preceptors for clinical decision making prior to the graduation was changed to a lack of formal preceptorship after graduation. Because most did not have access to a formal preceptor and many participants’ collaborators were unavailable to mentor, self-teaching was employed extensively by all participants post-graduation.

5.3. Theme III: Learning to care for complex patients

Theme III included participants’ experiences with learning how to care for complex clients before and after graduation. Participants’ ex- periences with learning complex patient care while in the program were random, “P16: it was like completely random because you were just lucky to get what you could get.” When advancing to clinical practice after graduation, participants reported “rude awakening” as they did not feel prepared to care for complex patients independently right after graduation. Participants reported the lack of support from their em- ployers’ administration as they did not yet feel equipped to care for complex clients and were in need of such support, “P16: So complex patients is what I really struggled on when I first became an NP … trying to like cram all that in, assess the patient, talk to them, figure out everything to order and change in like 15 min, it was very, very over- whelming at first.” Participants particularly struggled with poly- pharmacy, comorbidities, noncompliant clients, complex diagnoses, underserved, and less known patients. Without having adequate structured support, participants struggled with managing their time as well as took some of their work home. Learning to care for complex clients was preceptor and cite dependent while in NP program, which translated into an overwhelmingly steep transition post-graduation.

5.4. Theme IV: Learning and clinical environment

Participants’ experiences with clinical sites and preceptors prior to

graduation and collaboration support post-graduation were explored. Before graduation, most NPs reported the greatest challenge was finding and securing clinical sites and preceptors, which often led to mismatch between the preceptors, sites, and student’s learning needs, “P8: …. it was so hard you pretty much take anyone you could get and there was no way of telling if they were going be good teacher.” A mismatch between the clinical sites and students’ learning needs led to limited training opportunities available to NP students.

While locating the sites was one of the most stressful components of many participants’ experiences, frequent preceptor change with a lim- ited number of clinical hours spent with each preceptor led to shorter clinical rotations. In this study, short clinical rotations along with mismatch and lack of selectiveness when securing sites and preceptors led to a decrease in students’ autonomy during their clinical rotations. After graduation, participants’ relationship with providers they were learning from was reported as important to their successful transition to practice. Those participants who were learning alone reported more challenging transition experiences. Lack of selectiveness in sites and preceptors prior the graduation translated into the participants’ need for their employers’ support, which was often not available.

5.5. Theme V: Transitioning to a greater autonomy and new responsibilities

Participants’ experiences with advancing to a greater level of au- tonomy and new role responsibilities were explored. Increased de- pendency on preceptors along with decreased hands-on clinical ex- periences led to reduced autonomy during school clinical experiences, “P14: …. I never had a situation that I had to do it on my own in any of my rotations.” When in NP program, participants reported little in- dependent decision making, prescribing, or practicing differential di- agnoses.

After graduation, a sudden increase in autonomy, accompanied by the lack of support, led to participants feeling unprepared, “P14: … very challenging lots of frustration, lots of thinking I chose the wrong profession …. ” Participants reported having particular difficulties with autonomously prescribing multiple medications, coding, diagnosing, and laboratory testing interpretation. Many reported day dreaming of returning to their “safer” RN role; however, too much was already in- vested in NP degree. While participants were overwhelmed with their new responsibilities, they also appreciated the new autonomy level and began to embrace it when becoming more comfortable with new re- sponsibilities.

5.6. Theme VI: Embracing the role and identity confusion

Participants’ experiences with identifying with their new role of an advanced practice nurse were explored. While some participants re- ported that practicing in an RN role was helpful in learning how to be an NP, others reported it being confusing, “P16: I would go from I am the one making the decisions and ordering stuff during the week on patients too, now on the weekend I can’t do any of that, I am just like following orders, so it was really weird to live in both of those worlds at the same time.” After graduation, when in an NP role, participants re- ported that it was hard not to perform in both roles, RN and NP since their new role functions were not clearly defined. Such unclear role boundaries led to confusion about the scope of an NP role.

5.7. Theme VII: Transition reactions

Participants’ reactions to their experience with the transition before and after graduation were explored. While feeling stressed out about finding preceptors and sites when in the program was commonly re- ported, participants did not express concerns about their new role re- sponsibilities, “P11: I was not stressed out or anxious at all when I was an NP student, because the responsibility was not on me and now the responsibility is on me.” After graduation, most of reported emotional

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reactions to NP transition experience were negative. Participants felt fearful of making a mistake that could negatively affect their patients’ health, “P14: can you imagine killing somebody unintentionally, acci- dently because you did not get the right support; that left me very stressed out, very unfulfilled in my role as an NP, I thought I was going to be coming in making a world of difference … I feel alone…” It was important to explore participants’ feelings as part of their role transition experience because human feelings and reactions constitute an im- portant part of any experience.

6. Discussion

Findings suggested that NPs’ difficult transition to practice was re- lated to the lack of their preceptorship support in NP school and in NP work settings. The data showed ill-supported preceptorships when in NP programs. Lack of preceptorships after graduation was accompanied by employers expecting novice NPs to function at an expert level, fre- quently with minimal guidance. Understanding how NPs transition to practice and how their role transition is supported through preceptor- ships can be used to inform NP educators and organizations that hire NPs of the changes needed to strengthen NPs’ role transition.

The study findings provided insights into how NPs’ role transition is supported through preceptorship during the two transition stages, pre and post-graduation. An abrupt increase in autonomy from pre-gra- duation to post-graduation transition stage accompanied by the lack of support was this study’s central finding. The awareness of new re- sponsibilities did not take place until the post-graduation transition stage, which was the result of overreliance on preceptors for clinical decision making while in the program. Similarly, Cusson, and Strange (2008) found that the time of performing independently coincides with the time of becoming aware of new responsibilities. The abrupt increase in autonomy coincided with identity confusion.

Struggling to identify with their new role as an advanced nurse, trying to merge the roles of nursing and medicine, participants reported their role boundaries were blurred. This finding was consistent with Jangland et al. (2016) who reported that being positioned in between the two roles caused identity confusion. Similarly with Brown and Olshansky (1997), feelings of being an imposter were reported in this study. NPs enjoyed their new autonomy after settling into their role, confirming that increased autonomy level facilitates NP role transition (Faraz, 2017, 2019; Horner, 2017). However, the abrupt change from overreliance on preceptors while in the program to a poorly supported role transition post-graduation caused NPs to feel fearful and alone, which was consistent with previous studies on NP role transition (Barnes, 2015b; Brown and Oshlansky, 1997; Hart and Macnee, 2007; Heitz et al., 2004). This variation between the pre and post-graduation autonomy level combined with blurred role boundaries may be a culprit of NPs’ difficult role transition.

When exploring NPs’ experiences with preparation for their clinical rotations, consistent with Babcock et al. (2014), Flott and Linden (2016), and Roberts et al. (2017), this study’s findings confirmed that having an EMR access, becoming familiar with clinical site’s workflow, as well as preceptors’ and students’ expectations were critical. Frequent preceptor changes and shorter clinical rotations led to preceptors’ lack of comfort with their NP students, which caused an increase in ob- servation-only clinical hours. Similarly to Hallas et al. (2012) results, participants’ clinical hours did not translate into attaining all necessary competencies prior the graduation. Though hands on clinical experi- ences were always desired by participants, they experienced many observation-only clinical hours while adjusting to their new preceptors and learning the workflow of their clinical sites. To assist NP students with preparation for their clinical rotations, it may be beneficial to assign some observation-only clinical hours prior starting clinical ro- tations. It may also be of benefit to minimize preceptor and site changes to increase students’ clinical hours with each preceptor to allow learning of more complex skills. Lack of NP students’ preparation for

their clinical rotations was followed by rushed and variable pre- ceptorship process.

When exploring preceptorship during NPs’ role learning, incon- sistent preceptors’ teaching styles, lack of feedback, and preceptors’ heavy workload were identified. Bazzell and Dains (2017) reported the lack of guidelines to train preceptors and Marfell et al. (2017) under- lined the importance of feedback in mentoring. Preceptors’ heavy workload assignments combined with the lack of training on how to precept impacted NP students’ learning of their clinical skills. While preceptorship processes varied significantly, securing preceptors was also a challenge.

Challenges with finding and securing clinical sites were identified and consistent with AACN, 2015, Drayton-Brooks et al. (2017), and Erikson et al. (2014) findings. Poorly supported preceptorship com- bined with difficulties in finding clinical sites and preceptors impeded NPs’ clinical skills acquisition when in the program. Consistent with Hart and Bowen’ (2016) and Wilkes and Feldman (2017), this study showed that formal preceptorship was uncommon post-graduation leaving NPs to learn from others informally. Though, mentorship is essential to one’s successful transition to practice (Barnes, 2015a; Faraz, 2016; Farrell et al., 2015; Hill and Sawatzky, 2011; Zapatka et al., 2014), patient care takes priority decreasing time available for men- toring NPs (Bazzell and Dains, 2017; Forsberg et al., 2015; Giddens et al., 2014; Keough et al., 2015; Poronsky, 2012; Roberts et al., 2017). Training preceptors and decreasing their’ workload pre graduation, as well as creating formal preceptorships post-graduation, may provide a stronger foundation for NPs’ role transition.

When exploring how NPs learned to care for complex clients, lack of predictability of learning opportunities led to NPs graduating without having sufficient knowledge in managing patients on multiple medi- cations or those with multiple comorbidities causing them to doubt their skills. These findings were consistent with Jones et al. (2015) who found that NPs lacked preparation to care for complex elder patients. To address the gap in knowledge related to treating complex patients, it becomes necessary to include competencies specific to the complexities of patient care. Consistent with Hart and Bowen (2016), Jones et al. (2015), and Logan et al. (2015), many participants reported feeling unprepared to practice post-graduation. Similarly with the results of Fitzpatrick and Gripshover (2016), O’brien et al. (2009), and Sargent and Olmedo (2013), participants struggled to fulfill unrealistic em- ployers’ expectations in an absence of formal onboarding processes. After the graduation, post-graduation residency programs should pro- vide NPs with much needed mentorship component to close the gap between graduation at an entry level and employers’ requirements for expert NPs.

7. Limitations

This study was limited to NPs who were employed in an NP role in the United States for at least three months but no longer than five years. Additionally, data accuracy depended on participants’ recall. Because all participants had already graduated and started working in their new role, it was more difficult for them to recall their pre-graduation ex- periences. Recruitment was limited to those participants who vo- lunteered their participation. It is possible that NPs’ experiences with transition could steer them in their decision of whether to participate in this study. Due to the qualitative nature of this study, transferring the results outside the study setting and the population is not possible unless additional studies are conducted.

8. Conclusion

Understanding how NPs’ transition to practice process is supported through preceptorship is important in strengthening NPs’ clinical skills acquisition during the two transition stages, before and after gradua- tion. This study showed that while in school, NPs’ experiences with

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clinical skill acquisition were variable and ill-supported. Overreliance on clinical preceptors while in a program translated into an un- supported and stressful transition to practice post-graduation. Participants described that their role change after graduation started with excitement as they welcomed and embraced the new role, but quickly changed to the realization of new responsibilities of a new role combined with feeling unprepared to care for complex patients and the lack of transition support. Educators and employers have an opportu- nity to strengthen NPs’ transition to practice through restructuring the weakest but one of the most important elements of NP role transition, preceptorship. Training and adjusting preceptors’ schedules to allow learning to take place when in the program should provide NP students with the support necessary for them to increase autonomy of their clinical decision making. After the graduation, well-structured on- boarding programs and post-graduation residency programs should be employed to allow for a more gradual increase in autonomy to establish NPs’ safe transition to practice. The successful role transition process may lead to more NPs choose to stay in a role; thus, improving the quality and availability of health care services.

Funding sources

None.

Ethical approval details

IRB approval was obtained from the Walden University (Approval Number 01-16-18-0522648). All participants consented via e-mail and received an Amazon certificate of $10 dollars after the interview.

Declaration of competing interest

None.

Acknowledgements

Donna Bailey, PhD.

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Contents lists available at ScienceDirect

Nurse Education in Practice

journal homepage: www.elsevier.com/locate/nepr

Original research

The associations between the final clinical practicum elements and the transition experience of early career nurses: A cross-sectional study

Anu-Marja Kaihlanena,c,∗, Marko Elovainioa,b, Elina Haavistoc,d, Leena Salminenc, Timo Sinervoa

aNational Institute for Health and Welfare, P.O. Box 30, FI-00271, Helsinki, Finland bDepartment of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Finland c Department of Nursing Science, 20014, University of Turku, Turku, Finland d Satakunta hospital district, 28500, Pori, Finland

A R T I C L E I N F O

Keywords: Final clinical practicum Nurse Nursing education Transition

A B S T R A C T

The final clinical practicum before graduation prepares nursing students for the transition from a student to a nurse, but the essential elements of the final clinical practicum that enhance successful transition are not known. We examined the associations of five elements of the final clinical practicum with four indicators of the tran- sition experience in new nurses. We also tested whether psychosocial work characteristics modified these as- sociations. The study sample comprised 712 Finnish nurses who had graduated within the previous two years before the data collection (response rate: 18%). The data were collected using a questionnaire survey in 2018. The elements of the final clinical practicum included (1) the systematicness of the practicum, (2) teacher in- volvement, (3) the quality of supervision, (4) preparing for the demands of a nurse’s work and (5) being part of a professional team. Our results, based on linear regression analysis, showed that all the elements except the quality of supervision were associated with indicators of the transition experience (beta range: from 0.08 to 0.35). Job demands modified several of these associations. The findings of this study highlight the potential for well-implemented final clinical practicums to promote a smoother transition for new nurses.

1. Introduction

How to tackle the challenging transition from nursing student to fully qualified registered nurse is an old, yet still relevant, question that has gained considerable research interest during recent decades (Clare and van Loon, 2003; Edwards et al., 2015; Kramer, 1974; Rush et al., 2019). Transition is characterized as a multiphased process where new nurses go through changes in emotional, physical, socio-developmental and intellectual levels (Duchscher, 2009). At the start of their career new nurses encounter multiple work-related stressors, such as a lack of professional competence, high work demands, heavy workloads and a lack of support (Halpin et al., 2017; Labrague & McEnroe-Petitte, 2018). These partly unexpected psychosocial work characteristics and doubt of one’s own knowledge and skills may complicate the transition (Halpin et al., 2017; Regan et al., 2017) and increase the risk of emo- tional exhaustion (Laschinger et al., 2019; Lavoie-Tremblay et al., 2008), poor sleep (Hasson and Gustavsson, 2010; Zamanzadeh et al., 2015), role ambiguity and discrepancy (Tingleff and Gildberg, 2014; Walker et al., 2017), and burnout (Rudman and Gustavsson, 2011). Currently, the need to promote new nurses’ successful transition into

the health care workforce is increasingly evident due to the predicted worsening of the global nursing shortage (World Health Organisation, 2016; 2013). For example in the European Union area, approximately 120 000 new registered nurses enter the workforce annually (European Union statistics, 2016). However, simultaneously considerable amount of these new professionals (in some countries from 13 to 30 percent) have reported strong intentions to leave nursing (Leineweber et al., 2016; Rudman et al., 2014).

The critical importance of pre-graduate preparation that would help new nurses to adapt to the escalating expectations of professional practice is well acknowledged (Duchscher, 2009; Dwyer and Hunter Revell, 2016; Järvinen et al., 2018). The final clinical practicum before graduation, also called the senior practicum, is suggested to be a key factor in facilitating students’ sufficient readiness for transition (Casey et al., 2011; Kaihlanen et al., 2019b). Due to the chronic shortage of health care staff, new nurses are often expected to “hit the ground running”. Therefore, near the completion of the nursing programme there should be an emphasis on ensuring that students gain experiences of nursing realities, especially in terms of managing the workload (Halpin et al., 2017; Wolff et al., 2010) and demanding patient care,

https://doi.org/10.1016/j.nepr.2019.102680 Received 18 June 2019; Received in revised form 15 November 2019; Accepted 22 November 2019

∗ Corresponding author. National Institute of Health and Welfare, P.O. Box 30, FI-00271, Helsinki, Finland. E-mail address: anu.kaihlanen@thl.fi (A.-M. Kaihlanen).

Nurse Education in Practice 42 (2020) 102680

1471-5953/ © 2019 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).

T

which are shown to be major stressors for new nurses (Wu et al., 2012). Final clinical practicums should also include versatile opportunities for students to develop the needed knowledge and skills, experiences of varietal work–life challenges (Hartigan-Rogers et al., 2007; Kaihlanen et al., 2019a), the possibility to feel belongingness to a team (Levett- Jones and Lathlean, 2008; Newton et al., 2011) and adequate support and mentoring (Kaihlanen et al., 2013; Paliadelis and Wood, 2016).

Not just the pre-graduate clinical experiences but also the early- career psychosocial work environment play a role in the positive transition process from a student to a full member of a work organi- sation (Phillips et al., 2013; Laschinger et al., 2012). The most estab- lished model explaining the associations between psychosocial work characteristics and the employee outcomes is the Job Demand–Control Model by Karasek (1979). The model predicts possible adverse well- being and health outcomes at work as the result of the joint effects of high job demands (e.g. workload/time pressure) and low job control (e.g. skill discretion and decision authority). Conversely, if the job is highly demanding but the employee experiences a high level of job control, the work is not experienced as stressful and creates a better base for professional growth and facing challenges (known as the Active Job hypothesis) (Karasek and Theorell, 1990; Karasek, 1979). The de- mand–control theory has been utilised in the nursing context, for ex- ample, by Laschinger (2001) who found out that nurses whose high work demands were offset by a high level of control were more likely to have high confidence in their job-performance abilities and experienced greater opportunities to develop in their work (Laschinger, 2001). Also, a study of Svavarsdottir et al. (2018) showed that nurses who were working in high-strain jobs (with high demands and low control) per- ceived themselves as less effective and skilled than nurses whose job demands were combined with high job control (Svavarsdottir et al., 2018). Moreover, high strain jobs have been associated with greater turnover intentions among nurses (Chiu et al., 2009). Based on the above-mentioned findings, it is reasonable to assume that the level of job demand and job control may greatly affect newly graduated nurses’ transition period.

Despite the body of work in respect of final clinical practicums of graduating nursing students (e.g. Casey et al., 2011; Kaihlanen et al., 2018, 2019a) there is a lack of evidence about whether certain elements in the practicum actually affect the post-graduate transition experience. The aim of the present study was to investigate whether specific final clinical practicum elements are associated with the transition of nurses during their first years in practice. Additionally − given the potential contribution of high job strain in transitional challenges − we in- vestigated whether the possible associations between the practicum elements and transition are modified by post-graduate psychosocial work characteristics (job demands and job control).

2. Methods

2.1. Design and setting

This was a cross-sectional survey study conducted in Finland and reflects one part of a larger Competent workforce for the future (COPE) – study. In Finland the nursing education is arranged in the universities of applied sciences. The nursing programme (Bachelor of Health Care) consists of 210 study credits (taking 3.5 years), from which 90 credits are accomplished in clinical learning environments as required in the EU legislation (European Commission, 2005/36/EC). Because of the autonomy of universities of applied sciences, there are no common requirements or guidelines (e.g. about the structure or content) re- garding final clinical practicums. Thus, students’ final clinical practi- cums may vary significantly. Typically, the length of this practicum is between four and 10 weeks, it is performed during the final semester of studies and the supervision of a student is designated to one to two registered nurses in the unit. No final examination is required for li- censure and most students graduate soon after finishing their finalTa

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A.-M. Kaihlanen, et al. Nurse Education in Practice 42 (2020) 102680

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clinical practicums.

2.2. Participants and data collection

The participants of this study were all the registered nurses who had graduated within the last two years prior to the study (between 9/2016 and 6/2018). The total sample (n= 6797) was from the Finnish Central Register of Valvira (National Supervisory Authority for Welfare and Health). We obtained email addresses for 3942 nurses from the register of the Union of Health and Social Care Professionals in Finland (Tehy). An invitation letter with a link to the electronic questionnaire was sent to these nurses. The data collection, with three email reminders, was conducted between 1.11. and 21.12.2018. Altogether, 712 nurses re- sponded to the questionnaire, the response rate being 18%.

2.3. Instruments

The survey consisted of several instruments (Table 1). The Final clinical practicum elements were measured with a “Final clinical prac- ticum (FCP) experience” instrument that aims to measure how well different transition facilitating elements have been implemented in the final clinical practicum. The higher the score, the better the nurses’ FCP experience. The development and psychometric testing of the FCP ex- perience instrument have been described in detail in Kaihlanen et al. (2019b). The FCP experience instrument includes five subscales: (1) The systematicness of practicum (evaluating how systematically the practicum was planned and proceeded), (2) teacher involvement, (3) the quality of supervision, (4) preparing for the demands of a nurse’s work and (5) being part of a professional team. The instrument has shown good content and structural validity (Kaihlanen et al., 2019b).

Since we did not find any existing instrument to measure the tran- sition experience, we utilised the Transition Conceptual Framework of Duchscher (2009) in defining the central domains. The framework de- scribes the emotional, physical, socio-developmental and intellectual levels of the transition experience, and we chose four individual scales to demonstrate these domains: psychological distress, sleep problems, role conflict and ambiguity, and the perception of transition and edu- cational preparation, respectively. The selection of the scales was based on the Duchscher (2009) description about the four transition domains, as well as on other previous literature regarding transition-related is- sues (e.g. Hasson and Gustavsson, 2010; Kalkman, 2018; Watson et al., 2009).

The work characteristics were defined based on the Job Demand–Control Model (Karasek, 1979), which is the most established and widely tested model on the association between work related psychosocial factors and health (e.g. Kivimäki et al., 2006; Kivimäki et al., 2012).

The potential confounders included were age, gender, a previous lower health care degree (as a licensed practical nurse), work experi- ence gained during studies, the work environment of the final clinical practicum, familiarity of the placement from previous clinical practi- cums, the length of the practicum, whether the supervisor remained the same during the practicum, the current work environment, the length of time in the current employment, the work schedule and whether the current work unit was the same as the final clinical practicum place- ment.

2.4. Statistical analysis

As preliminary analyses, we examined whether the potential con- founders could technically act as confounders in the association be- tween the five final clinical practicum elements (The systematicness of practicum; Teacher involvement; The quality of supervision; Preparing for the demands of a nurse’s work; Being part of a professional team) and the four indicators of transition experience (Psychological distress; Sleep problems; Role conflict/ambiguity; Perception of transition and

educational preparation) using multivariate ANOVA. This was done by including all the potential confounders and practicum elements in the same model to predict each transition indicator. Those potential con- founders that showed significant association with any of the transition indicators were included in the main analyses. These were: gender, work experience gained during studies, the current work environment and the work schedule.

The associations of the practicum elements with the four transition indicators were examined using linear regression analysis in three steps. In step one, each transition indicator was regressed on each practicum element separately. In step two, each transition indicator was regressed on all practicum elements. In step three, the models estimated in step two were adjusted for job demands, job control, and the four potential confounders identified in the preliminary analysis. Cases with missing values were dropped from the analysis.

The potential interaction effects between the practicum elements and work characteristics (job demands and job control) were also ex- amined with linear regressions. Job demands and job control were re- coded into dichotomous variables for the analysis by using a median split; values below the median were labelled as low job demands/low job control, and values above the median as high job demands/high job control.

Analyses were conducted with IBM SPSS Statistics 25 and R (3.5. 0) statistical software.

2.5. Ethical considerations

This study was carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for research involving human subjects (World Medical Association, 2001). The ethics committee of the National Institute for Health and Welfare in Finland provided the ethical approval for this study (THL/253/6.02.01/ 2018). In the invitation letter respondents were informed about the purpose of the study, the voluntariness of participation and informed that the data would only be handled by the members of the research group and then without any identifying information. Submitting the questionnaire was seen as consent to participate in the study.

3. Results

3.1. Sample characteristics

Close to 90% of the nurses were female, and their age varied be- tween 21 and 61 years old, the average being 31.1 years old. Over 38% of the nurses had a previous health care degree as licensed practical nurses (a Vocational Qualification in Social and Health Care, 180 credits). Most commonly nurses had gained 6–11 months of work ex- perience (external to their studies) during their education, the length of their final clinical practicum was 10 weeks and the practicum place- ment was in specialised health care. Specialised health care was also the most common current work environment. The length of current em- ployment was most often between six and 11 months and every fourth nurse worked in her or his former final clinical practicum placement. The majority of the nurses worked in three shifts. The characteristics of the participants and the descriptive statistics of the study variables are presented in Table 2 and Table 3.

3.2. Associations between final clinical practicum elements and transition indicators

The results from the unadjusted (univariable) models and adjusted (multivariable) models are presented in Table 4. In the adjusted models, the systematicness of the practicum was associated with all the transi- tion indicators: nurses with higher scores in systematicness had less psychological distress, less sleep problems, less role conflict/ambiguity and more positive perception of transition and educational preparation.

A.-M. Kaihlanen, et al. Nurse Education in Practice 42 (2020) 102680

3

Higher scores in teacher’s involvement and in preparing for the de- mands of a nurse’s work in the practicum were associated with more positive perception of transition and educational preparation. Higher score in being part of professional team in the practicum was associated with less sleep problems and more positive perception of transition and educational preparation. The quality of supervision had no statistically significant associations with any of the transition indicators.

3.3. Interaction effects between final clinical practicum elements and work characteristics (job demands and job control)

The final clinical practicum elements and job demands had several interaction effects on the transition indicators. There were significant interactions between the systematicness of the practicum and job de- mands (β = 0.19, p = 0.048), teacher involvement and job demands (β = 0.13, p = 0.013) and being part of a professional team and job demands (β = 0.15, p = 0.037) for the psychological distress. The systematicness of the practicum and job demands (β = 0.22, p = 0.034), preparing for the demands of a nurse’s work and job de- mands (β = 0.25, p = 0.015) and being part of a professional team and job demands (β = 0.26, p = 0.015) had significant interaction for the perception of transition and educational preparation. Significant in- teraction was also found between teacher involvement and job de- mands for the sleep problems. (β = 0.23, p = 0.004).

Nurses with better teacher involvement in the final clinical prac- ticum who currently had low job demands experienced less psycholo- gical distress and less sleep problems compared to nurses with high job demands. Higher scores for systematicness and for being part of the professional team in the practicum were associated with less psycho- logical distress in both the high-job-demands and low-job-demands groups, but the effects were stronger in the low-job-demands group. Similarly, higher scores for systematicness, for preparing for the de- mands of a nurse’s work and for being part of a professional team in the practicum were all associated with more positive perception of transi- tion and educational preparation in both job-demands groups, but the effect was stronger in the low-job-demands group (Fig. 1.).

4. Discussion

This study aimed to investigate whether specific elements pre- viously identified as essential in the final clinical practicum of nursing education were associated with the transition experience of early career nurses and whether the possible associations were modified by their psychosocial work characteristics (job demands and job control). Firstly, we found several associations between the practicum elements and the variables demonstrating the four transition domains. The re- sults of this study indicate that having a good final clinical practicum experience can be beneficial for new nurses and ease their transition process. Secondly, we found several interactions between the final clinical practicum elements and job demands. Based on the results, it seems that among those nurses who end up working in health care

Table 2 Characteristics of the participants.

Variable n %

Gendera Female 627 88.9 Male 76 11.1

Licensed practical nurse Yes 274 38.5 No 437 61.5

Work schedulea Day job 155 22.1 Two shifts 113 16.1 Three shifts 389 55.4 Other 45 6.4

The length of current employment 1–5 months 148 21.4 6–11 months 248 35.9 1–2 years 243 35.2 3–5 years 21 3 6–10 years 17 2.5 11–15 years 7 1 Over 15 years 6 0.9

Current work environmenta Emergency care 107 15.4 Psychiatric and substance abuse services

94 13.5

Specialised health care 265 38.1 Elderly care 161 23.1 Reception work 36 5.2 Other 33 4.7

Work experience during studiesa No experience 32 4.5 1–5 months 143 20.2 6–11 months 215 30.3 1–1.5 years 124 17.5 1.5–2 years 74 10.4 Over 2 years 121 17.1

Practicum placement Emergency care 161 22.8 Psychiatric and substance abuse services

95 13.4

Specialised health care 342 48.4 Elderly care 50 7.1 Reception work 29 4.1 Other 30 4.2

The same work unit as that of her/his practicum placement

Yes 159 22.5 No 547 77.5

Length of the practicum (weeks) 3 10 1.4 4 67 9.4 5 93 13.1 6 135 19.0 7 82 11.6 8 69 9.7 9 21 3.0 10 184 26.0 11 19 2.7 12 29 4.1

A familiar practicum placement Yes 345 48.8 No 362 51.2

Having the same supervisor during the practicum

Yes 637 90.1 No 70 9.9

a Variables controlled in the analysis.

Table 3 Descriptive statistics of the study variables.

Variable Scale Mean SD.

Final clinical practicum elements The systematicness of the practicum 1–5 4.42 0.59 Teacher involvement 1–5 3.48 1.05 The quality of supervision 1–5 4.18 0.92 Preparing for the demands of a nurse’s work 1–5 4.28 0.62 Being part of a professional team 1–5 4.19 0.79

Transition indicators Emotional (Psychological distress) 1–4 2.09 0.77 Physical (Sleeping problems) 1–6 2.59 1.11 Socio–developmental (Role conflict/ambiguity) 1–5 2.38 0.70 Intellectual (Perception of transition/educational preparation) 1–5 3.63 0.90

Work characteristics Job control 1–5 3.67 1.12 Job demands 1–5 3.70 0.80

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environments with a considerably high job demands, such as time pressure, the benefits of having a good final clinical practicum experi- ence are not that distinct and may not exceed the negative effects of having high job demands. This seems reasonable because many newly graduated nurses do not feel prepared to manage the nurses’ normal work and patient load (Halpin et al., 2017; Labrague et al., 2019) and the high job demands and heavy workloads are shown to be the most significant stressors affecting negatively on the transition period (Labrague & McEnroe-Petitte, 2018). On the other hand, autonomy and decision latitude have previously been linked to new nurses’ better well-being (Lavoie-Tremblay et al., 2008), but in this study the job control did not moderate any of the associations between the final clinical practicum and transition.

From the five final clinical practicum elements that were examined, the systematicness of the practicum was associated with all the four transition indicators. The systematicness indicated that the practicum

placement served the student’s individual learning needs, the student had concrete learning objectives, the progress was planned and there was sufficient time for achieving the set objectives. Basically, the sys- tematicness was related to having a well-organised practicum that en- hanced students’ possibilities to improve the potential competence de- ficiencies − and simultaneously, confidence deficiencies − before stepping into the nurse’s role. Previous studies have shown that grad- uating students’ perceptions about their competence can be un- realistically high since all the practicums, including the final, are per- formed under supervision and without the full experience of a nurse’s duties and responsibilities (Kajander-Unkuri et al., 2014; Theander et al., 2016). Therefore it is very likely that new nurses experience a considerable amount of stress and feelings of deficiency in their tran- sition when the actual competence level is realised in their first work- place. Multiple studies have shown a link between the in-adequate educational preparation and the unrealistic expectations that newly

Table 4 The associations between final clinical practicum elements and the transition indicators (1. psychological distress, 2. sleep problems, 3. role conflict/ambi- guity, 4. perception of transition and educational preparation).

Coefficient (univariable) Coefficient (multivariable)

1. Psychological distress

The systematicness of the practicum −0.28 (−0.37 to −0.18, p < 0.001) −0.17 (−0.30 to −0.05, p = 0.008) Teacher involvement −0.06 (−0.12 to −0.01, p = 0.020) −0.00 (−0.06 to 0.05, p = 0.923) The quality of supervision −0.11 (−0.17 to −0.05, p < 0.001) 0.08 (−0.01 to 0.17, p = 0.072) Preparing for demands −0.22 (−0.31 to −0.13, p < 0.001) −0.03 (−0.16 to 0.10, p = 0.658) Being part of a professional team −0.19 (−0.26 to −0.12, p < 0.001) −0.10 (−0.21 to 0.00, p = 0.056) Job demands low – – high 0.55 (0.44–0.66, p < 0.001) 0.50 (0.39–0.61, p < 0.001)

Job control low – – high −0.30 (−0.41 to −0.19, p < 0.001) −0.19 (−0.30 to −0.08, p = 0.001)

2. Sleep problems

The systematicness of the practicum −0.38 (−0.52 to −0.24, p < 0.001) −0.26 (−0.45 to −0.07, p = 0.007) Teacher involvement −0.12 (−0.20 to −0.04, p = 0.003) −0.05 (−0.13 to 0.03, p = 0.201) The quality of supervision −0.14 (−0.23 to −0.05, p = 0.002) 0.12 (−0.02 to 0.25, p = 0.085) Preparing for demands −0.23 (−0.37 to −0.10, p = 0.001) 0.05 (−0.14 to 0.25, p = 0.594) Being part of a professional team −0.27 (−0.37 to −0.16, p < 0.001) −0.21 (−0.37 to −0.05, p = 0.009) Job demands low – – high 0.69 (0.53–0.85, p < 0.001) 0.65 (0.48–0.82, p < 0.001)

Job control low – – high −0.20 (−0.37 to −0.04, p = 0.017) −0.03 (−0.19 to 0.14, p = 0.737)

3. Role conflict/ambiguity

The systematicness of the practicum 0.28 (0.20–0.37, p < 0.001) −0.19 (0.08–0.30, p = 0.001) Teacher involvement 0.06 (0.01–0.11, p = 0.026) 0.00 (−0.04 to 0.05, p = 0.952) The quality of supervision 0.14 (0.09–0.20, p < 0.001) −0.01 (−0.06 to 0.09, p = 0.693) Preparing for demands 0.17 (0.08–0.25, p < 0.001) −0.07 (−0.18 to 0.04, p = 0.207) Being part of a professional team 0.18 (0.11–0.24, p < 0.001) −0.06 (−0.03 to 0.15, p = 0.217) Job demands low – – high −0.53 (−0.63 to −0.44, p < 0.001) 0.48 (−0.57 to −0.38, p < 0.001)

Job control low – – high 0.45 (0.35–0.55, p < 0.001) 0.36 (0.27–0.45, p < 0.001)

4. Perception of transition and educational preparation

The systematicness of the practicum 0.66 (0.55–0.76, p < 0.001) 0.35 (0.21–0.49, p < 0.001) Teacher involvement 0.18 (0.11–0.24, p < 0.001) 0.08 (0.02–0.14, p = 0.009) The quality of supervision 0.32 (0.25–0.38, p < 0.001) −0.04 (−0.14 to 0.06, p = 0.430) Preparing for demands 0.59 (0.49–0.69, p < 0.001) 0.22 (0.07–0.36, p = 0.003) Being part of a professional team 0.45 (0.37–0.52, p < 0.001) 0.15 (0.03–0.27, p = 0.012) Job demands low – – high −0.25 (−0.38 to −0.11, p < 0.001) −0.13 (−0.26 to −0.01, p = 0.040)

Job control low – – high 0.24 (0.10–0.37, p = 0.001) 0.07 (−0.05 to 0.20, p = 0.242)

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qualified nurses have about their new role (Higgins et al., 2010; Tingleff and Gildberg, 2014).

Thus, ensuring that students have realistic perceptions about one’s competence level, as well as about the demands and requirements of the professional practice, would be of importance in final clinical practi- cums (Kaihlanen et al., 2019a). Evidently students cannot be equipped with all the knowledge and skills required in demanding and constantly changing health care, but instead of preparing students to handle the stable and predictable clinical situations, a practicum should aim to prepare them for the complex and acute nature of nursing, which is the current reality in many work environments (Wolff et al., 2010). This statement is supported by our findings as the nurses who had better opportunities to prepare for the demands of a nurse’s work in the practicum had more positive perceptions about their transition and educational preparation. Having positive pre-entry perceptions can be beneficial in regard to the retention of early career nurses, because it has shown to moderate the association between the post-graduate work-characteristic and professional commitment (Guerrero et al., 2017).

Quite surprisingly, the quality of the supervision (including e.g. a trustful, competent and committed supervisor) was the only practicum element in this study that was not associated with any of the transition indicators, except when examined individually. In previous literature adequate supervision and mentorship have been seen as the main ele- ments in facilitating students’ transition into professionals by increasing their sense of preparedness and decreasing the stress about starting working life (Kaihlanen et al., 2013; Lavoie-Tremblay et al., 2018; van Rooyen et al., 2018). This contradictory finding does not necessarily indicate the unimportance of the supervision in final clinical practi- cums, but it is possible that the potential benefits do not extend as far as to one to two years post-graduation. Also, the benefits may not exceed the significance of post-graduate mentoring and social support, which are known to be essential in promoting early career nurses’ successful transition, professional socialisation (Edwards et al., 2015; Ferguson, 2011) and retention (Brook et al., 2018). However, the nurses in this study who evaluated themselves as being more part of a professional team in the practicum, with a supportive and collegial atmosphere, had

more positive perceptions about their transition and educational pre- paration. This finding is in line with previous studies (Callaghan et al., 2009; Kaihlanen et al., 2019a) and suggests that instead of having a designated accountable supervisor in the final clinical practicum, per- haps a more collective approach should be prioritised in order to help the students to gain a sense of belonging to the unit and team. Already being a visible and acknowledged member of the team as a student could improve the confidence of new nurses regarding their inter- personal skills, which in turn could help them to adjust to their new roles more quickly (Chung et al., 2008; Kumaran and Carney, 2014). Further studies, for example with longitudinal or experimental designs, are needed to determine the most beneficial supervision practices in the final clinical practicum.

5. Strengths and limitations

Certain limitations should be taken into account when interpreting the findings of this study. Firstly, the cross-sectional analyses do not allow causal interpretations of any identified associations. Secondly, based on the rather small response rate, we cannot state that the results of this study are representative. However, the sample size of 712 early career nurses can be considered large in the context of Finnish nursing education research, and a strength is that the participants represented different health care environments, geographical areas and phases of post-graduate employment. By controlling the analysis with multiple potential confounders, we also tried to minimise the possibility of sampling bias. Thirdly, we are aware that the four individual mea- surements that were chosen to demonstrate the transition only provide a limited description of a multidimensional experience. Lastly, it should be considered that despite several of the significant univariate asso- ciations between the practicum elements and transition indicators being lost in the multivariate models, some of the practicum elements may still intermediate through other practicum elements.

6. Conclusion

Our results suggest that final clinical practicum experiences affect

Fig. 1. Interaction effects between final clinical practicum elements and job demands (Transition = Perception of transition and educational preparation; Distress = Psychological distress; Sleep = Sleep problems).

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nurses’ first years of employment. In particular, the systematic planning and implementation of the final clinical practicum and opportunities to become an active member of the work community should be considered for promoting a smoother transition from a student to a nurse. The potential benefits of a good final clinical practicum experience may especially be seen among those nurses who do not experience a con- siderably high job demands, including time pressure in their first work environments. This study adduced new knowledge about the link be- tween the pre-graduate preparation and the transition experience of early career nurses.

Author statement

Anu-Marja Kaihlanen: Conceptualization, Methodology, Formal analysis, Investigation, Writing – Original Draft, Writing – Review & Editing, Visualization, Marko Elovainio: Conceptualization, Methodology, Formal analysis, Writing – Review & Editing, Visualization, Elina Haavisto: Conceptualization, Methodology, Writing – Review & Editing, Leena Salminen: Conceptualization, Methodology, Writing – Review & Editing, Timo Sinervo: Conceptualization, Methodology, Investigation, Writing – Review & Editing, Visualization, Supervision.

Funding

This work was supported by the Strategic Research Council (SRC) of the Academy of Finland (project 303605).

Declaration of competing interest

None.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https:// doi.org/10.1016/j.nepr.2019.102680.

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