Perspectives of Chinese New Nurses Regarding Successful Transition: A Qualitative Study

ABSTRACT Background Transition issues have been discussed for many decades, yet little is known about successful transition expectations in the context of Chinese culture. Purpose This article was designed to describe the expectations of newly graduated nurses in China regarding successful transition. Methods A qualitative, descriptive study design was employed, and a purposive sampling method was used to recruit interviewees. All of the one-to-one conversations were held in a quiet room to ensure privacy. All of the interviews were transcribed and then analyzed using thematic analysis. Results Nineteen new nurses were recruited from seven tertiary hospitals and participated in the in-depth interview process. Transition success, that is, “professional metamorphosis,” was revealed through the four themes of “being competent in nursing work,” “establishing a professional identity,” “establishing comfortable interpersonal relationships,” and “achieving balance between work and life.” Conclusions/Implications for Practice Chinese new nurses expect their successful transition to achieve a professional metamorphosis in many aspects. A successful transition is not only a journey of professionalization but also a process of socialization. New nurses expect to achieve both maturity in their work and wisdom in life. The results of this study provide a greater understanding of transition issues in the context of Chinese culture. Thus, support and strategies cannot be limited to interventions designed to improve working competence but should be individualized to help new nurses achieve a smooth transition.


Introduction
Newly graduated nurses (NGNs) are registered nurses who have graduated from academic settings and have fewer than 2 years of work experience (Alshawush et al., 2022).Because of the academic-practice gap, NGNs must make the transition from supervised learners into autonomous practitioners (Huston et al., 2018).This is a process of learning, adjustment, and socialization in a new work environment (Huston et al., 2018).Some researchers have defined this transition period for new nurses as the first 2 years of employment after graduation as this period is the most challenging time for them (Dyess & Parker, 2012).Nurses often describe this transition period as "uncomfortable, vulnerable, stressing, difficult, or tumultuous" (Bennett et al., 2017).They may experience a large gap and mismatch between their given responsibilities and their actual competencies (Mellor & Gregoric, 2016) and are required to manage an increasing number of patients with complex conditions and relationships.To compound this problem, these issues often occur simultaneously (Hofler & Thomas, 2016).
Although transitioning is critical to NGNs becoming efficient and effective professionals, this process is not always successful.To integrate into their new roles successfully, NGNs must improve their competencies in clinical decision making and critical thinking, organizing and prioritizing, and evidence-based practice (Kim & Shin, 2020).Thus, the transition process is a long and arduous journey for NGNs and also a source of stress (Zhang et al., 2019).Unsuccessful transitions may not only negatively impact the quality of patient care (van Rooyen et al., 2018) but also adversely affect NGNs' long-term views on their profession and their retention willingness (Kim & Shin, 2020).An estimated 35%-60% of new graduates change their positions or leave the nursing field within the first year of clinical practice (Ma et al., 2021).In one longitudinal study, the turnover rate of NGNs in China was reported to be around 33.2% (Zhang et al., 2019).
To address this issue, many support strategies, including residency programs, internship practice programs, and mentoring relationships, are provided to help NGNs transition into nursing professionals (Speight et al., 2019).Residency programs are the most common strategies used to support NGNs.However, these programs vary in content, duration, and structure among countries and even among hospitals in the same country (Baumann et al., 2018).Internship practice programs have been shown to effectively smooth the transition process using a rotation of 4-6 weeks, although these programs vary significantly from university to university (Canbolat & Hisar, 2022).Currently, two primary strategies are employed by the Chinese government to address this transition issue.One is a mandatory 8-month nursing internship practice during the last year of university education (Zhang et al., 2019).The other is a suggested 24-month standardized training for new nurses (China National Health Commission of People's Republic of China, 2016).However, the delivery of these training programs is not standardized in terms of availability, structure, or rotation (Ma et al., 2021).
Consensus regarding the elements involved in a successful transition would help solve the abovementioned problems and guide the provision of support needed by NGNs (Chargualaf & Tse, 2017).Researchers have described the transition of NGNs from various different aspects.Some hold the transition of NGNs to be both a process and an outcome and that it should have an outcome or an end product because the transition occurs over time, which is limited (Murray-Parahi et al., 2016).Meleis considered transition to be a process linking changes with experienced time, with the completion of the transition implying the achievement of comparatively greater stability (Meleis, 2010).Craig et al. regarded increased role independence and confidence as the salient issues in terms of a successful transition (Craig et al., 2012).Su identified the ultimate goal of transition as achieving professional identity (Su et al., 2021), which sometimes involves adjusting one's personal identity during the transition process (Wyllie et al., 2019).On the basis of a survey of the related literature, no research has explored the meaning of transition in the context of Chinese culture.
A thorough understanding of the structure and elements of transition success is necessary to gain comprehensive insight into the transition issue.The perceptions and expectations from the perspective of Chinese NGNs offer the potential to enrich the current scholarly understanding of successful transition and provide a reference for providing better support to NGNs.To the best of the authors' understanding, no previous study on this subject has been conducted in China.Therefore, the objective of this study was to explore the perceptions and expectations of Chinese NGNs regarding transition success.

Design, Settings, and Participants
A qualitative descriptive approach was used in this study.This study was conducted at seven tertiary hospitals in five cities (Beijing, Tianjin, Shanghai, Lanzhou, and Chongqing) in China.A purposeful sampling strategy was used.To increase participation and sample diversity, NGN diversity was purposively recruited to reflect differences in terms of gender, level of education, department, and months of clinical nursing experience.The "Training Outline for New Nurses," promulgated by the Chinese government in 2016, strongly encourages that tertiary hospitals provide 24-month training to NGNs (China National Health Commission of People's Republic of China, 2016).In China, NGNs are typically defined as registered nurses with less than 24 months of experience (Wu et al., 2023).In this study, the inclusion criteria were NGNs who (a) were employed as nurses for the first time, (b) worked in the inpatient unit of a tertiary hospital, and (c) had clinical experience of more than 3 months but less than 2 years.Otherwise qualified individuals who had either served in management roles in nursing departments or been employed before graduation were excluded.Six NGNs in Beijing and Tianjin initially signed up for the study, none of whom had any prior direct involvement with the authors.

Data Collection
One-on-one, in-depth interviews were conducted in a faceto-face setting with the participants.The initial interview guide was prepared based on a literature review beforehand by the research group, with a follow-up meeting held to evaluate and remove ambiguous or leading questions.Next, three professors were invited to assess the comprehensiveness and appropriateness of the questions in light of the study aims.The interview guide was subsequently refined into several broad questions and then modified and finalized after three pilot interviews.The three interview guide questions included "What does the successful transition mean to you?", "What do you expect yourself to be when passing the transition process successfully?",and "What would you like to highlight as the most important aspect of the successful transition?"On the basis of the responses, more probing questions were asked when necessary to elaborate on the meaning of the responses and clarify uncertainties.Each interview ended with the question: "Is there anything more you would like to add or share?" All of the interviews for this study were conducted from July 2018 to July 2019 by the first author, who had participated in doctoral training core courses focusing on qualitative research with the support of the China Medical Board.All of the interviews were conducted in private in a meeting room near each participant's work unit.Each conversation was conducted in Mandarin, lasted for around 40-90 minutes, and was recorded on a Sony ICD-TX650 with participant permission.
Each interview was transcribed and coded immediately afterward and validated by relistening.Data analysis was performed concurrently with data collection to help identify data saturation, which was met after interviewing the 14th participant.To confirm data saturation, five more NGNs were interviewed, which resulted in no new codes or information.
The Journal of Nursing Research Weiguang MA et al.With the confirmation of data saturation, the recruitment of new participants stopped.

Ethical Considerations
This study was approved by the Ethics Committee of Chinese Academy of Medical Sciences/Peking Union Medical College (No. X170315005).Informed consent was given to all participants after the researcher introduced the study purpose and participant rights.In addition, the participants were asked to sign written informed consent to allow their interviews to be audio-taped.The names of participants, their institutions, and related personnel were anonymized during audio recording, transcription, and data analysis.The participants were free to withdraw at any stage of this study without stating a reason.

Data Analysis
A thematic analysis approach was used to define themes and subthemes to provide a rich thematic description of the interviews and transcripts (Braun & Clarke, 2006).Two researchers read through all of the transcripts multiple times using a holistic approach to obtain a broad picture of their perceptions and experience.The analysis continued using a detailed approach, with researchers reading the transcripts carefully line-by-line.The transcripts were coded using NVivo 12.0, and significant statements were selected and compiled.On the basis of the coding of each transcript, the two coders reached a unanimous decision on the themes.The coding was conducted in Chinese initially, followed by the translation of findings into English by one of the authors, who studied as a visiting scholar in the United Kingdom and is fluent in both Chinese and English.Quotations were selected to highlight the particular ways in which the participants described themes.

Rigor
Lincoln and Guba's four criteria (Lincoln et al., 1985) were applied.To ensure credibility, the accuracy of each transcript was checked by two researchers.In addition, to explore the experience of the participants accurately and adequately, the two researchers conducted their analyses separately and then reached a consensus on the developed themes.Dependability was achieved through continuous discussion and reflection among all of the researchers across the entire analysis process.Confirmability was achieved using field notes and the reflexive documents of the first author.In addition, relevant quotes were included to ensure that all of the findings were rooted in the data.Transferability was achieved using a purposeful sampling strategy, which enrolled participants currently practicing in different clinical departments and geographical areas.We applied consolidated criteria to report qualitative research guidelines to ensure the transparency of research reporting (O'Brien et al., 2014).

Core Theme: Professional Metamorphosis
Transition success means professional metamorphosis for NGNs.Eighteen of the 19 participants described experiencing a long and painful transition process as well as this process as being an indispensable part of their path to professional maturity.One participant working in the emergency room described her experience: The process is really a painful but indispensable part on my way to professional maturity.Everyone has to pass this process.It's just like a caterpillar must pass through the cocoon stage to become a butterfly.I have to find what and how to adjust to be a professional nurse through many failures and frustrations.This is really painful.Actually, I have worked for 14 months, but still cannot say I am there.(N2) Transition success, that is, "professional metamorphosis," was revealed in the four themes that emerged in this study.These four themes, reflecting the expectations of new nurses for transition success (see Table 2), are discussed below with quotations from the participants to support the themes and enrich understanding.

Theme 1: Being Competent in Nursing Work
Being competent was the most common theme identified in the data set.All of the participants stated that, as a professional nurse, the first and most important sign of a successful transition is being competent in their work.As N3 described, "I think being competent in my work is the most important thing.I am a professional nurse, so I try to be competent in my work, just like other experienced nurses.I must provide safe and qualified nursing services for my patients.It is my duty.Without this, I can never say that I have successfully passed this period."Some (11 of 19) of the participants further shared their experience self-judging whether they were competent in their work.
Subtheme 1: Competency is a subjective feeling Seven of the participants identified being competent as a subjective feeling and remarked that competent nurses should have a sense of professional self-confidence.They expected that they would be able to work independently and to organize and prioritize their nursing work.
When I successfully transition into a competent nurse, I will be able to work independently.I will know all the work needed to be done during my shift, and what I should do in order.I will even be able to predict changes in patient conditions and prepare for my next work in advance.Everything will be under control.When I am there, I think I will have this feeling and level of confidence.(N1) Subtheme 2: Competency can be objectively assessed Another four participants stated that being competent can be objectively perceived.Because each industry and position has its own requirements, meeting the related requirements is considered by NGNs as an objective way to evaluate their level of competency: "We will be tested when finishing our rotation in each clinical unit, which usually includes common theoretical knowledge and skills in the specialty.Passing these tests means we are competent for the basic requirements in different specialties.It is an objective way for me to evaluate whether I am competent enough to achieve a successful transition" (N5).
Two of the participants considered responses from people in their work environment as an objective way to help them assess their competence and develop professional self-confidence.As N2 stated, "If you are not competent, nobody would want to be your partner because you may slow down overall work progress.That's been my experience from the beginning.When a colleague is willing to work with me, I think I am doing well in my work.Also, when my patients, colleagues, doctors, or leaders tell me 'you did a good job,' I will have more self-confidence in my competence."

Theme 2: Establishing a Professional Identity
This theme revealed the change in attitude of participants toward the nursing profession through the transition process.NGNs usually began their professional practice holding negative emotions.After struggling for a successful transition, their attitudes change as they acclimate to clinical nursing practice and their professional identity solidifies.
Subtheme 1: Eliminate resistance to the nursing profession Most (17) of the participants related that they were reluctant to enter the nursing profession and did so only after failing to enter other more-preferred fields of study.NGNs regularly perceive a gap between reality and the ideal, especially at the beginning of their clinical practice.However, after a long period of struggle for a successful transition, they eliminate their resistance to the nursing profession through self-adjustment and ultimately accept their professional roles.Commonly used words by the participants include "settled down" and "acceptance," reflecting their mature and calm attitude toward the nursing profession.
I was forced to enter the nursing profession because I didn't do well on the college entrance examination.I also found that sometimes actual nursing work is quite different from what I imagined and expected.But, after I gained some insight into nursing, I decide to settle down.I decided to accept my roles and responsibilities as a nurse.It's true that nursing has many disadvantages; but it has merits as well.(N6) Subtheme 2: Acceptance helps fulfill roles Some participants acknowledged the importance of accepting their nursing career, believing it would help push them to work to fulfill their roles and help establish their professional identity.As N18 described, "Once you accept your current roles, you will be happy to receive training and exercises to develop related skills and knowledge.Once you are able to fulfill your roles, you will emerge with a sense of achievement in nursing work.Now, I am pretty sure that I will continue working in the nursing field, and will try to be a good nurse." Theme 3: Establishing Comfortable Interpersonal Relationships This theme reflects the socialization process within the transition process.In this study, the participants considered interpersonal interaction to be an indispensable part of their transition.They desired the comfortable relationships and keenly perceived the changes.
Subtheme 1: Desire for comfortable relationships Eleven of the participants stated they perceived interpersonal relationships as an indispensable part of their transition, because "can you imagine spending more time with your colleagues than family?Colleagues are very important for your adaption of work.They have more experience than you.They can show you what and how to do your work.So, they are really helpful and even determine whether you can 'survive' as a nurse" (N8).However, slightly more than half (10) of the participants admitted that, although it was easy to talk about, it was difficult to build relationships with their colleagues.Even so, they still desired a comfortable interpersonal relationship that should come as part of a successful transition.As N11 mentioned, "Colleagues surely play a key role in our transition.But it is difficult for me to build a relationship with them.Most of the time, I just can't get in a word when they start talking on some topic.Besides, it's strange for me to make friends with them.They were my teachers several months ago!But I am a nurse now, just like them.Our relationship has changed.We are equals now.So I desire to be one of them."Subtheme 2: Perceive positive changes in the relationship Five of the participants stated that their successful transition was accompanied by a change in their interpersonal relationships.As N7 conveyed, "I am still not there, but I believe that I felt a change in my relationships when I achieved a successful transition.It is a kind of feeling that I was not just working together in the same unit, but actually one of them.Like I'd integrated into the group and was one of them.'Yes, you are an insider now.' Everyone feels comfortable at that time."

Theme 4: Achieving Balance Between Work and Life
Seven of the participants addressed the relationship between work and life.At the beginning of their transition, NGNs generally invest significant time and energy into their work to cope with their new circumstances and new roles.Thus, after their successful transition, they would like to reestablish a more equitable work-life balance.As N12 shared, "I did spend a lot of time studying the knowledge and skills required for my work.There were so many things for me to learn, but time was limited.It seemed work was the only thing in my life.I was too busy to enjoy life.But, if I achieve a successful transition, I must give some of my time back to my life.Work is still important, but not the only thing in my life anymore.I should leave some time for life." Subtheme 1: Expect balance between work and life Although it is difficult to separate work and life, seven of the participants expected to achieve an equitable balance between the two.One participant reflected their eagerness for relaxation after work: "My heart rate increased when my phone rang at home.I was nervous to hear that I did something wrong on duty.Even when I closed my eyes in bed, I can't help thinking about whether I had failed to do something at work.So I am eager for relaxation after work.I hope I can sleep well without worrying about my work and patients" (N3).

Discussion
This study was designed to explore the perceptions and expectations of Chinese NGNs regarding successful transition into nursing practice.To our knowledge, this was the first qualitative research study to explore this issue in China.This study provided a greater understanding of the issues affecting and underlying the transition process in the context of Chinese culture.The core theme in this study, professional metamorphosis, reflects the meaning of successful transition and the fact that NGNs look forward to achieving positive change in multiple aspects.In addition, the core theme reflects the interaction between the individual and their organization and the changes in interpersonal and intrapersonal relationships across the transition process, which mirrors previous findings that new nurses must manage various aspects of the transition process (Murray-Parahi et al., 2016).
Being competent in nursing work was identified in this study as the most important indicator of transition success.As professional nurses, the participants expected to be competent in their work, which reflects the professional essence The Journal of Nursing Research Weiguang MA et al. of transition.Meleis also postulated that the mastery of certain skills to manage a new state is an indicator of successful transition (Meleis, 2010).Moreover, the participants in this study explained that both their subjective feelings and objective tests during their rotation could help assess their own readiness or competence for their work.This finding is an important addition to the findings of previous studies, and helps understand the expectations of Chinese new nurses with regard to successful transition.
Similar to a previous study (Moore & Hofman, 1988), professional identity was identified as an important psychological basis for new nurses to do their job well, which implies that the successful transition of NGNs, in which professional identities are rebuilt, is a process of making sense.In this study, most of the participants were reluctant to enter nursing at the beginning of their employment.Other researchers in China have also reported feelings of "unfairness" and inferiority among Chinese nurses, as nurses are typically regarded as assistants, rather than partners, to doctors (Ye et al., 2020).However, after struggling for a successful transition, these participants gradually realized that nursing has not only disadvantages but also merits.Finally, they ended their resistance to the nursing profession and settled down.This professional identity, in turn, will help these nurses fulfill their professional roles and responsibilities.
The findings of this study also reflected the expectations of Chinese new nurses with regard to comfortable workplace relationships, revealing the socialization aspect of transition.Previous studies have shown that NGNs may encounter interpersonal relationship difficulties at the beginning of their transition and may feel lonely and isolated from professional groups (Spence Laschinger et al., 2018).In China, "blame" culture tends to victimize NGNs more than experienced nurses, contributing significantly to the interpersonal vulnerability and eagerness for harmonious interpersonal relationships in the former group (Ye et al., 2020).In this study, the participants expressed they perceived interpersonal relationships to be an indispensable part of their transition.Despite the difficulties of this process, they still desired comfortable interpersonal relationships after achieving a successful transition.
The importance to successful transition of work-life balance was also highlighted in this study, with the participants expressing expectations to bring work and life back into harmony.Consistent with other studies, this harmonious state between work and life reflects the eagerness of NGNs for a sense of personal control over their schedules and responsibilities during the transition process (Reynolds et al., 2023).Under the current nursing education system in China, new nurses are hired in their early 20s after graduation (Ma et al., 2021).Mao explained these Generation Y nurses have a strong preference for a work-life balance and desire not to be overly exhausted after work to allow them to enjoy their life (Mao et al., 2021).Spence Laschinger et al. also found Generation Y nurses to desire work that is compatible with their lifestyle (Spence Laschinger et al., 2018).Work-life imbalance is highly and positively linked to increased job turnover intentions among NGNs and is thus considered an indicator of unsuccessful transition (Hussein et al., 2016).

Limitations
The qualitative and small sample nature of this study does not permit the results to be generalized to the larger NGN population in China.Although the sample may be sufficient for data saturation for qualitative studies, it was purposively selected based on the established inclusion criteria.In addition, all of the participants were from China, and further research including a greater diversity of cultural contexts may be pursued to enrich the results.

Conclusions
The findings of this study reveal the meaning and expectations associated with successful transition from the perspective of NGNs in China.NGNs in China expect to metamorphosize professionally in many aspects during the transition process.For new nurses, a successful transition is not only a journey of professionalization but also a process of socialization.They expect to achieve both maturity in their work and wisdom in life.The results of this study enrich scholarly understanding of transition issues in the cultural context of China.

Implications for Practice
The transition issue has been discussed for many decades, but studies on this subject in China are limited.The findings of this study may facilitate greater understanding of Chinese nurse expectations for a successful transition and the development of strategies to smooth their transition journey.The findings indicate that support and strategies for NGNs should not be limited to work competence training but should be individualized and cover a wide spectrum of issues, including how to build interpersonal relationships, how to balance work and life, and how to look rationally on the nursing profession.

Subtheme 2 :
Try to bring work and life into harmonyFour of the participants stated their expectation of bringing life and work back into harmony.This reflected the wisdom of the participants in dealing with the work-life relationship.As N6 described, "Some of my colleagues do well in their work and live happily in their life.That's the real success.I think work and life can exist at the same time harmoniously.I don't want to insert too much of my work into my life.Anyway, the purpose of work is to build a better life.Enjoy work when I work, and enjoy life after work.That harmonious state is what I expect from a successful transition."

Table 2
Summary of Themes and Subthemes (N = 19)Once you accept your current roles, you will be happy to receive some training or exercises to develop those skills or knowledge required to complete the roles.Once you can fulfill your roles, you will emerge with a sense of achievement in nursing work.Now I am pretty sure that I will continue working in the nursing field, and try to be a good nurse.Some of my colleagues do well in their work and live happily in their life.That's the real success.I think work and life can exist at the same time harmoniously.I don't want to take too much work into my life.Anyway, work is for a better life.Enjoy work when I work, and enjoy life after work.
Colleagues surely play a key role in our transition.But it is difficult for me to build a relationship with them.Most of the time, I just can't get in a word when they start a topic.Besides, it's strange for me to make friends with them.They were my teachers several months ago!But I am a nurse now, just like them.Our relationship changed.We are equal now.