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The transition from student to nurse can be overwhelming but support and mentoring should help cushion the shock
The move from student to fully fledged nurse is difficult, and it is estimated that more than a quarter of nurses leave their posts within three years of qualifying.
Nursing Standard. 38, 9, 23-25. doi: 10.7748/ns.38.9.23.s11
Published: 06 September 2023
We look at why it is so difficult and what can be done to prevent what has been dubbed ‘transition shock’.
The pressures for staff on the front line are a clear issue, according to a report by Middlesex University published in 2022.
NHS England asked researchers to look at what support nurses need, in an effort to improve the way preceptorship programmes work in the health service.
They said a lack of formal and consistent preceptorship programmes, combined with increasing demands being placed on services, meant newly qualified nurses could find themselves thrown into providing care with little support.
It cited research in one region of England that found that one in 11 trusts did not provide any preceptorship support, and almost half had no formal policy.
RCN newly registered nurses network co-chair Daniel Branch says it is an issue. ‘You are meant to have a period where you are supernumerary after qualifying. I did – I was completely supernumerary for six to eight weeks, then phased in with time away for training and support and time off in the rota,’ he says.
‘But not everyone does get that. The pressures on the front line mean some are pushed straight in to providing care. That’s not fair.’
Universities have reported that there is a shortage of clinical placements and the quality of learning nurses receive is not always as good as it should be.
Mr Branch says those who studied during the COVID-19 pandemic in particular have experienced this. ‘It caused so much disruption that the quality of learning was not always the best,’ he says.
‘On top of that, the pressures mean that on some of your placements, staff simply do not have the time to spend with you. Patient care has to take priority, understandably, but it can perhaps leave you a little under-prepared.’
His network co-chair Alex Dray, who qualified last year and works as a children’s nurse on a surgical ward, agrees.
She says her placements were good and gave her confidence, but adds that they only really help prepare you for the ‘basic’ care, such as observations, documentation, and intravenous and oral medications.
It leaves a lot of learning to do on the job. ‘When you first walk on the ward it’s definitely overwhelming,’ says Ms Dray.
‘I don’t think anything can fully prepare you for the change from student to nurse. There’s so much you then begin to learn. You still have to become competent in all things that you may have been doing as a student.’
Emotional and financial stress is another key factor, says Mr Branch, who works as a learning disability nurse in the community.
A study published in the International Journal of Nursing Studies in 2022 found high levels of burnout and emotional exhaustion in nurses in the early months after qualifying.
The starting salary for a nurse in England is £28,407, which means anyone who takes up a full-time post will have to begin paying back their tuition fees immediately.
‘It is particularly difficult at the moment with the cost of living crisis,’ Mr Branch says. ‘Starting salaries have not kept up with inflation and you may have all sorts of extra costs, such as moving home and setting yourself up in a different part of the country when you qualify.
‘When you add to that the challenge of meeting new people and finding your feet in a new job it can be pretty overwhelming.’
Indeed, research by the University of Hull has illustrated the importance of what it calls ‘orientation’ factors. Researchers interviewed students who had spent their final placement in their eventual first place of work. Ahead of learning nursing skills, they said they valued the simple benefits, such as knowing where the coffee room was, the door codes and who was who.
‘Because you’ve qualified doesn’t mean you have all the knowledge; you learn this all over time’
Alex Dray, co-chair, RCN newly registered nurses network
Management development consultant Desiree Cox, who specialises in preceptorship, says starting any new job is difficult but there are unique pressures for nurses. ‘It is a difficult period, those first few months,’ she says.
According to NHS England, preceptorship is a structured start for newly qualified practitioners, with the main aim of welcoming and integrating those who are newly registered into their new team and place of work.
‘You have such huge responsibilities as a nurse and that puts added stress on top,’ says Ms Cox. ‘Getting support from your employer is important – you need people there for you emotionally and professionally in those first few months especially.’
Claire Blake qualified in 2020 and took up a post in general practice, but only lasted eight months before she left the role.
‘Making the transition from being a student to a qualified nurse and treating patients is the most difficult thing I have had to do in my career and all my study. It was scary. I felt like an imposter,’ says Ms Blake, pictured.
‘I had done all the study, but I felt like I was not ready. A big problem was that I didn’t receive enough support. I had two days of shadowing and was then basically thrown into seeing patients. There was virtually no ongoing support.
‘I was good with things like wound care and bloods and ECGs, but then I started being asked to do things I just wasn’t trained to do, such as cervical screening. I had to say no. It makes you really question yourself. I left the job after eight months.
‘My next role at another practice was completely different. I shadowed the other nurses for two weeks and had a mentor who provided me with ongoing support. It made a massive difference.
‘They wanted me to take on the asthma clinic and sent me on a training course. I even ended up supervising a student at one point.
‘Looking back now, I should have spoken up at that first practice and at least let them know I needed more support.
‘You should never be afraid to ask for help.’
There are no mandatory requirements of what sort of support the NHS should provide for newly registered nurses. But in 2022 NHS England produced a preceptorship framework to encourage greater consistency. It recommends a set of core standards that all health employers are being asked to achieve by September 2023, with a set of gold aspirational’ standards to aim for afterwards.
The core standards state that a preceptorship programme should last a minimum of six months, with at least two weeks where the newly registered nurse is supernumerary. There should be three meetings with a dedicated preceptor mentor who has at least 12 months’ experience. The gold standard asks that preceptorship programmes last 12 months with more regular meetings.
Ms Cox says meeting these standards is most challenging for smaller organisations such as general practices or social care providers. But, she says: ‘We are seeing some great innovation – GP practices are working together in training hubs to coordinate support. The Capital Nurse programme in London has led the way.’
One of the most advanced is the hub coveringsix boroughs in south east London. One nurse in each primary care network works as a practice nurse facilitator, with the main part of the role being to preceptor newly registered nurses and nursing associates. They are paid for nine hours a month to do this.
New recruits meet with the facilitator in group sessions. During these meetings, everything from training needs to well-being support is offered. Those who are really struggling can get one-to-one support.
‘I think we are going to see real progress made in the coming months and years – newly qualified nurses should receive better support,’ adds Ms Cox.
The variability in the quality of preceptorships is also acknowledged in the NHS Long-Term Workforce Plan, published in June 2023. It recommends NHS trusts ensure uniformity in the programmes by following the national preceptorship programme, including a minimum of two weeks’ supernumerary status for newly registered nurses.
Benchmarking work by NHS England before its framework was published showed around half of NHS employers were achieving the core standards. Ms Cox says progress has been made since then. But if nurses find themselves in roles where they are not getting support, they should not be afraid to ask.
‘Speak to your line manager – most people will want to help newly qualified nurses,’ she says. ‘Find out if there is a dedicated team – most trusts will have something in place, while in general practice we are seeing these regional training hubs being established.
‘When you apply for jobs ask them what support they have so you know what to expect.’ Ms Dray agrees. ‘You should not be afraid to ask questions – you don’t have to know everything. Just because you’ve qualified doesn’t mean you have all the knowledge; you learn this all over time.’
She says there are also things you can do to help yourself. Lean on your peers that you qualified with – keep in touch with them and share your experiences.
‘Make sure you have a good support system outside work, and when you have days off, make sure you do something that you enjoy – even if it’s a short walk somewhere,’ says Ms Dray. ‘Enjoy the process. You’ve worked hard to get here so don’t always be doubting yourself.’
But remember, she says, ‘it’s okay not to be okay’.