Most nurses will undergo at least one setting, specialty, or role transition during their professional careers, with many making multiple transitions as interests, skills, and opportunities develop (Dellasega, Gabbay, Durdock, & Martinez-King, 2009). Successful nurse transitions help to build a skilled nursing workforce and improve healthcare safety, quality, and outcomes (Hirschkorn, West, Hill, Cleary, & Hewlett, 2010; Lartey, Cummings, & Profetto-McGrath, 2014). As such, national organizations, such as the Association for Nursing Professional Development (ANPD), National League for Nursing (NLN), and National Council of State Boards of Nursing (NCSBN), call for structured support programs to ensure successful transitions (ANPD, 2018; NCSBN, 2018; NLN, 2018).
Although professionals acknowledge the importance of ensuring that nurses experience successful transitions, resources (time, money, effort, personnel) are most commonly focused on new graduate nurse transitions, frequently in transition-to-practice or new nurse residency programs (ANPD, 2018; NCSBN, 2018; NLN, 2018). Increasing patient acuity and complexity, comorbidities, and intricate healthcare technologies challenge recent new graduate nurses as they transition from student to practicing nurse (Clipper & Cherry, 2015; Duchscher, 2008; Hofler, 2008; Hunt, 2016; Silvestre, Ulrich, Johnson, Spector, & Blegen, 2017). Although it is imperative to support new graduate nurses as they experience this sometimes difficult transition to practice, it is also necessary to assist experienced nurses as they undergo the numerous transitions they may make throughout their careers. Experienced nurses are critical to healthcare systems as they positively influence improvements in safety, quality, and patient outcomes (Hill, 2010; Hirschkorn et al., 2010; Lartey et al., 2014). Some authors recognize the need to support experienced nurses as they transition to academic faculty, clinical educator, and advanced practice roles. However, nurses' need for support during lateral transitions, wherein a registered nurse (RN) moves from one clinical area to another, goes largely without notice in the literature.
Experienced nurses will likely transition to several new organizations or specialties as they progress through their careers. The term new-to-setting nurse will be used to describe this type of experienced nurse lateral transition. For example, a new-to-setting nurse may transition from a medical-surgical unit to a critical care unit. New-to-setting nurse transition needs may be overlooked by nursing and human resources leaders, current staff, and nursing professional development (NPD) practitioners, with an assumption that these nurses will have less difficulty when transitioning and acclimating to a new environment (Dellasega et al., 2009). This may be an unsafe assumption according to empirical and experiential evidence; some authors suggest new-to-setting nurses have unique and perhaps even more challenging needs when transitioning (Dellasega et al., 2009). The authors witnessed and experienced these challenges and the need for improved support for individuals engaged in new-to-setting nurse transitions. Understanding and improving new-to-setting nurse transitions begins with the concept of transition itself. Different conceptualizations of the concept transition can create different ideas on supporting and managing (Gale & Parker, 2014) new-to-setting nurses' transition experiences; thus, a concept analysis of new-to-setting nurse transitions was warranted.
PURPOSE OF THE ANALYSIS
Despite the term transition being used frequently in the literature, it is not often explicitly defined. Thus, the purpose of this concept analysis was to (a) clarify the often used and vaguely defined concept of transition, (b) analyze the concept of transition as it relates to new-to-setting nurse transitions, (c) develop a theoretical definition of the concept new-to-setting nurse transitions, and (d) contribute to the body of evidence regarding transitions in nursing. These aims are consistent with the purposes of concept analyses (Walker & Avant, 2011). The remaining six concept analysis steps followed here are iterative in nature and include identifying (a) all uses of the concept; (b) defining attributes; (c) a model case; (d) borderline, related, and contrary cases; (e) antecedents and consequences; and (f) empirical referents (Walker & Avant, 2011). It is anticipated that this analysis will lay the groundwork for deeper understanding and ongoing support of nurses making a transition to a new professional setting.
LITERATURE REVIEW
Search Methods
Various sources were examined in an effort to capture comprehensive definitions and uses of the concept of transition. First, dictionary definitions and thesaurus synonyms were reviewed. Next, nursing professional organizations' websites, specifically ANPD, NCSBN, and NLN, were searched to ascertain uses of the concept of transition. An NPD expert was consulted regarding the definition of transition. The Core Curriculum for Nursing Professional Development, 5th Edition (Dickerson, 2017) was also examined. In addition, the CINAHL, PubMed, PsycINFO, and ERIC databases were explored using the search terms [transition], [concept], [theory], [definition], and [change] across nursing, medicine, psychology, and education disciplines. Advanced search criteria included peer-reviewed articles available in English with full-text online. Articles published prior to 2008 were excluded in an effort to target current conceptualizations. Dissertations and gray literature were also excluded. The search of both qualitative and quantitative sources yielded 99 results. Reference lists of located resources were also searched using the same criteria. After applying inclusion and exclusion criteria and verifying that the concept of transition was present, 20 articles were selected for review. Finally, Meleis' transitions theory (Meleis, Sawyer, Im, Hilfinger Messias, & Schumacher, 2000) was reviewed for use of the concept transition. In all sources, implicit and explicit uses of the concept transition were considered.
Findings and Analysis
Table 1 summarizes the sources, definitions, and uses of the concept transition explored during the search. Once selected, sources were examined for themes. Transition was explored first to enable the authors to then further analyze the concept new-to-setting nurse transitions. The various sources revealed the themes of transition as a (a) linear shift or (b) complex process.
Transition as a linear shift
Merriam-Webster defines transition as a "passage from one state, stage, subject, or place to another" (Merriam-Webster, Inc., 2018, para. 1). Several authors from various professional perspectives support this definition, understood by their explicit definitions of transition (Duchscher, 2008; Gale & Parker, 2014; Hussey & Smith, 2010; Im, 2014; Jonczyk, Lee, Galunic, & Bensaou, 2016; Meleis et al., 2000). For example, Im (2014) defines transition as a "passage from one life phase, condition, or status to another" (p. 20). Duchscher (2008) defines transition as "a passage or movement from one state, condition, or place to another" (p. 442). One can appreciate the notion of a linear shift in these definitions. Implicit definitions and synonyms of transition also align with the idea that a transition is a linear shift (ANPD, 2018; Dickerson, 2017; Dictionary.com, LLC, 2018; Fritz, 2018; Grassley & Lambe, 2015; Hofler, 2008; Hunt, 2016; Levin, 2010; NCSBN, 2018; NLN, 2018; Silvestre et al., 2017; Suplee & Gardner, 2009). The terms movement and change can be understood in the implied definitions of transition. Hofler (2008), for example, discusses new graduate nurse transitions, or movements, to the work environment. Grassley and Lambe (2015) and Fritz (2018) consider the change from the role of nursing clinician to nurse educator.
In addition, of the authors who offered an explicit definition of transition, several outline multiple definitions for transition (Duchscher, 2008; Gale & Parker, 2014; Im, 2014). Duchscher (2008), for example, differentiates between transition and new graduate nurse transition by presenting the stages of professional role transition. These definitions seem to suggest authors see the concept of transition and their specific concept, for example, new graduate nurse transitions and care transitions, as separate. In other words, though transition is seen as a linear shift, specific transition concepts are often seen as complex processes instead.
Transition as a complex process
Merriam-Webster's second definition of transition describes transition as "a movement, development, or evolution from one form, stage, or style to another" (Merriam-Webster, Inc., 2018, para. 1). Although this definition still clearly denotes a shift, the definition also suggests a process in transitions. Various sources agree and describe transition as a complex, nonlinear process (Ashley, Halcomb, Brown, & Peters, 2018; S. Bindon, personal communication, February 28, 2018; Cavendish, Connor, & Rediker, 2017; Clipper & Cherry, 2015; Dellasega et al., 2009; Duchscher, 2008; Gale & Parker, 2014; Holt, 2008; Hui et al., 2014; Larner, 2014; Meleis et al., 2000; Phillips & Evans, 2017). Holt (2008), for example, states that role transition is "a process of moving from one role to another through a series of events or episodes" expanding upon this to say it "may be an ongoing developmental process" (p. 119). Meleis et al. (2000), in their transition theory, also suggest transition complexity by listing over 10 distinct properties of transition, including time span, process, milestones, questions, skills, and capacities.
The sources reviewed for this analysis revealed two themes of transition as a (a) linear shift or (b) complex process. Although some authors presented explicit definitions, others used the concept of transition without defining it, thus leaving the reader to gather meaning implicitly. It is evident that transition is a concept of universal interest as all perspectives attempt to define, understand, and improve various transitions for the individual(s) experiencing them. Professional role transitions are frequently described and are clearly an area of great concern. The authors analyzed the specific concept of new-to-setting nurse transitions, including developing a theoretical definition for the concept.
DEFINING ATTRIBUTES
The defining attributes of the concept new-to-setting nurse transitions are that it is a complex, nonlinear process involving movement from one setting to another. The authors determined these attributes by ascertaining characteristics "that appear[ed] over and over again" in the explored sources (Walker & Avant, 2011, p. 162). Once identified, the attributes were then appraised and altered as needed for the concept new-to-setting nurse transitions.
A Complex, Nonlinear Process
Although some authors view transition as a linear shift, many consider it a complex, nonlinear process (Ashley et al., 2018; S. Bindon, personal communication, February 28, 2018; Cavendish et al., 2017; Clipper & Cherry, 2015; Dellasega et al., 2009; Duchscher, 2008; Gale & Parker, 2014; Holt, 2008; Merriam-Webster, Inc., 2018; Phillips & Evans, 2017). This complex, nonlinear view was deemed most appropriate for the concept new-to-setting nurse transitions. As true with job and role transitions, new-to-setting nurses can experience a tremendous amount of stress when transitioning to new settings, organizations, or units (Ashley et al., 2018; Dellasega et al., 2009; Levin, 2010). Levin (2010) discusses role transition as one of the most stressful and challenging life events one can experience. The new-to-setting nurse may be expected to "hit the ground running" despite unfamiliarity with their new setting (Dellasega et al., 2009, p. 312; Levin, 2010, p. 57). The new-to-setting nurse may feel confident in some respects, whereas at other times they will feel frustrated, lost, or even angry (Ashley et al., 2018; S. Bindon, personal communication, February 28, 2018; Dellasega et al., 2009). These feelings will likely occur throughout the transition process as the nurse grows accustomed to his or her new environment. In their exploratory study, Dellasega et al. (2009) describes three stages in the experienced nurse transition process, that is, assessing expectations, realistic appraisal, and adjusting. An accompanying graphic denotes the complexity and nonlinear nature of this process with its bidirectional arrows between processes (Dellasega et al., 2009). These stages reflect some of the same experiences described in the phases of reality shock experienced by new nurses; honeymoon, shock, recovery, and resolution (Kramer, 1974). New-to-setting nurse transitions are complex, nonlinear processes that continue to evolve as the nurse experiences the transition.
Involving Movement From One Setting to Another
In addition to being complex and nonlinear processes, new-to-setting nurse transitions involve moving from one setting to another. This attribute was discovered across sources (ANPD, 2018; Ashley et al., 2018; S. Bindon, personal communication, February 28, 2018; Clipper & Cherry, 2015; Dickerson, 2017; Duchscher, 2008; Fritz, 2018; Hofler, 2008; Holt, 2008; Hussey & Smith, 2010; Im, 2014; Jonczyk et al., 2016; Larner, 2014; Levin, 2010; Meleis et al., 2000; Merriam-Webster, Inc., 2018; NCSBN, 2018; NLN, 2018; Silvestre et al., 2017; Suplee & Gardner, 2009). Movement was thus identified as key in new-to-setting nurse transitions. Setting (organization, unit, area, and/or specialty) clarifies this attribute to new-to-setting nurse transitions. The element of detaching oneself from the previous setting (Jonczyk et al., 2016) was omitted. It is not clear whether new-to-setting nurse transitions involve or should involve an element of detachment.
CONCEPT CASES
According to Walker and Avant (2011), a model case provides a clear example (Walker & Avant, 2011) of the concept of interest. A model case (Table 2) was constructed to include all defining attributes of new-to-setting nurse transitions. In this model case, the nurse moves from one setting, as an acute care RN role, to another, as a critical care RN role. The process is complex, influenced by many factors including preceptor support. The RN experiences both feelings of accomplishment and frustration during her transition, denoting a nonlinear process.
A borderline case contains most but not all defining attributes of a concept (Walker & Avant, 2011). A borderline case for new-to-setting nurse transitions is presented in Table 2. Though this process is complex, requiring new accesses and introductions, among other things, it is linear. The nurse gains confidence and continues to grow as an RN in the ICU.
Related cases include instances related to the concept new-to-setting nurse transitions but do not contain all of the defining attributes. Related cases describe similar or parallel concepts and have names of their own (Walker & Avant, 2011), for example, new graduate nurse transitions. Two related cases are provided in Table 2. In Related Case 1, the nurse undergoes a complicated 3-month onboarding process as the nurse moves from student nurse to practicing nurse. However, the newly licensed nurse does not have experience as an RN and thus does not qualify as moving settings. The newly licensed nurse has experienced a new graduate nurse transition. In Related Case 2, the nurse moves into a nurse educator role after being a direct care staff nurse. Though this process is complex and nonlinear, it is not a lateral transfer and thus cannot be considered a new-to-setting nurse transition. The nurse is experiencing an advanced role transition, transitioning from a clinician to a nurse educator.
Contrary cases are ones that are clearly not reflecting the concept new-to-setting nurse transitions (Walker & Avant, 2011). In the contrary case (Table 2), no process is occurring nor has any movement taken place. This contrary case does not represent a new-to-setting nurse transition.
ANTECEDENTS
The antecedents in new-to-setting nurse transitions are (a) an experienced nurse who holds a current position, (b) motivation(s), and (c) an open position. Antecedents are "events or incidents" that must occur or be in place before the concept (Walker & Avant, 2011, p. 167).
An Experienced Nurse Who Holds a Current Position
In order for a new-to-setting nurse transition to take place, an experienced nurse needs to be present. There is disagreement on exactly what constitutes an experienced nurse; however, generally sources agree the nurse must have at least 1 year, with some suggesting 2-5 years, of experience to be considered experienced (Hill, 2010). For this concept, new-to-setting nurse transitions, at least 1-year practicing as a nurse will constitute an experienced nurse. This experience could be in a different organization, specialty, or level of care than the intended movement setting. The nurse must hold a current position in order for him or her to move from a position to a position.
Motivation(s)
For a new-to-setting nurse transition to take place, there needs to be a motivation or reason for the movement. Motivations can be varied, including internal, external, voluntary, or mandatory (S. Bindon, personal communication, February 28, 2018; Dellasega et al., 2009; Hussey & Smith, 2010; Im, 2014; Jonczyk et al., 2016; Levin, 2010; Phillips & Evans, 2017). Multiple motivations may also be present. These motivations will be important influences in concept processes and subsequent consequences. In other words, nurses who voluntarily engage in new-to-setting nurse transitions will likely have different experiences and different outcomes than do nurses who had no choice in making a professional transition.
An Open Position
In order for the new-to-setting nurse to experience a transition, there must be a position for him or her to go to. Thus, an open position is an essential antecedent in new-to-setting nurse transitions.
CONSEQUENCES
The consequences, or outcomes (Walker & Avant, 2011), of the concept new-to-setting nurse transitions are successful or unsuccessful transitions. Example benefits from successful transitions and detrimental outcomes from unsuccessful transitions are presented in Table 3.
EMPIRICAL REFERENTS
Empirical referents help one recognize or measure the defining attributes of the concept of new-to-specialty nurse transitions (Walker & Avant, 2011). The first empirical referent emulates the defining attribute of involving movement from one setting to another; empirical referents and defining attributes often match in concept analyses (Walker & Avant, 2011). Also, changes in individual factors, such as fluctuating changes in skills, confidence, competence, satisfaction, self-image, or attitudes, will be present and can help identify the complex, nonlinear process. Existing tools could be used and/or modified to measure these changes. Example tools include the Casey-Fink Nurse Retention Survey (Casey & Fink, 2009) or Press Ganey Survey (Press Ganey Associates, Inc., 2018). Empirical references will help subsequent instrument development and measurement of the concept new-to-setting nurse transitions (Walker & Avant, 2011). Table 3 summarizes the defining attributes, antecedents, consequences, and empirical referents for the concept new-to-setting nurse transitions.
STATEMENT DEVELOPMENT
Based on the preceding analysis of the concept, new-to-setting nurse transitions, the following theoretical definition was formulated:
A new-to-setting nurse transition is a complex, nonlinear process wherein an experienced nurse makes a lateral movement from one setting to another, with consequences for healthcare professionals and systems.
This theoretical definition introduces the critical defining attributes of the concept new-to-setting nurse transitions and will be important in future practice, research, and theory (Walker & Avant, 2011). Potential applications of this concept to other areas of nursing must also be considered.
APPLICATION TO NURSING PRACTICE, RESEARCH, AND THEORY
Nursing Practice
This concept analysis revealed new-to-setting nurse transitions as complex, nonlinear processes; however, current practices seem to suggest new-to-setting nurse transitions are instead considered to be linear shifts. This difference in conceptualization results in a need for different support and management of new-to-setting nurse transitions (Gale & Parker, 2014). This change in perspective can help to inform NPD practitioners on approaches to individualize transition experiences for nurses new to a setting. New-to-setting nurses are often expected to quickly become contributing team members despite being new to an environment (Dellasega et al., 2009; Levin, 2010). Orientation and postorientation programs for new-to-setting nurses may be inadequate or even nonexistent. For example, Ashley et al. (2018) reported that new-to-setting nurses transitioning from acute care to primary care had five or fewer orientation days to support their transition. Conceiving new-to-setting nurse transitions as complex, nonlinear processes instead of linear shifts reminds nurse leaders, human resources partners, staff colleagues, and NPD practitioners that experienced nurses possess valuable knowledge and skills but still need focused support and education to succeed in a new setting. Adjustments are needed beyond simply shortening orientation time based on assumptions that they can orient more quickly than a new graduate nurse. Close attention must be given to assessing existing competencies and learning needs, establishing relationships on the unit, and maintaining a close connection with NPD practitioners and other resources. Structured training, mentorship, and preceptor development programs must be established and tailored for new-to-setting nurse needs. For example, Ashley et al. identified support factors, which could have assisted acute to primary care new-to-setting nurse transitions, such as (a) improved and longer orientations; (b) greater leadership, colleague, preceptor, and mentor supports; (c) opportunities for team meetings; (d) improved communications between nurses and with medical staff; and (e) enhanced socializations. Current literature regarding new graduate and advanced nursing transitions can serve as a foundation in creating orientation and support programs. However, future study is needed to adequately support, manage, and evaluate new-to-setting nurse transitions. From both a unit and organizational perspective, goals for new graduate nurses and new-to-setting nurses are the same, that is, that nurses are safe, competent, satisfied team members who intend to stay in their position. The benefits of successful transitions (Table 3) can be realized with thoughtful planning and consistent support of nurses making complex, nonlinear new-to-setting transitions.
Nursing Research and Theory
Though this concept analysis identified characteristics of new-to-setting transitions, the analysis was not able to identify exactly what processes are occurring. In their exploratory study, Dellasega et al. (2009) were the only ones to address the new-to-setting nurse transition process; they identified the phases as assessing expectations, realistic appraisal, and adjusting. It is not clear if these phases are accurate in describing new-to-setting nurse transitions. Future, more rigorous research is needed to verify, alter, or discover the new-to-setting nurse transition process. Research questions could include the following:
* What is involved in a new-to-setting nurse transition?
* What are the perceived needs in new-to-setting nurses' transitions from the perspective of the transitioning nurse, preceptor, and organization? What are the challenges to a successful transition? What facilitates a successful transition?
* What evidence-based strategies can help support new-to-setting nurse transitions?
* How does new-to-setting nurse transition reflect novice to expert and/or reality shock models?
In addition to guiding future study, this concept analysis and the theoretical definition introduce the critical attributes of new-to-setting nurse transitions, which may be helpful in developing an instrument to measure the concept (Walker & Avant, 2011). The concept may also be a vital building block in future or existing nursing theories (Walker & Avant, 2011). From an operational perspective, this work may contribute to future consideration and subsequent development of new-to-setting nurse transition programs.
CONCLUSION
Though nurses undergo at least one transition during their professional careers, many will make multiple transitions as they define their skills and interests and refine their practice. Included in these transitions is often at least one new-to-setting transition. Though nursing professionals acknowledge the many benefits of successful transitions, attention and resources are often focused on new graduate transition needs. New-to-setting nurse transition needs can be overlooked if we assume that these nurses will transition more smoothly than a new graduate nurse. This concept analysis revealed new-to-setting nurse transitions can be considered equally if not more challenging as new graduate nurse transitions. Conceptualizing new-to-setting nurse transitions as complex, nonlinear processes represents a divergence from current perceptions and suggests subsequent adjustments are needed to improve the transition experience. Though current literature can serve as a starting point in new-to-setting nurse transition support and management, future research is needed to identify processes occurring within new-to-setting nurse transitions. In properly supporting new-to-setting nurse transitions, individual, team, and organizational benefits of successful transitions will be realized.
References