Facing registration: The expectations and the

unexpected
Mary Mooney
*
School of Nursing and Midwifery, Trinity College Dublin, 24 DOlier Street, Dublin 2, Ireland
Accepted 22 November 2006
KEYWORDS
Newly qualied nurses;
Grounded theory;
Nursing roles;
Stress
Summary This paper reports on newly qualied nurses experiences of the transi-
tion from being a nursing student to becoming a registered nurse. The aim of the
study was to ascertain how newly qualied nurses perceived their role transition
in an Irish general hospital. Data were gathered using in-depth interviews with 12
nurses who were within one year of qualication. A grounded theory approach
was used to generate, analyse and synthesise the data. The ndings revealed that
newly qualied nurses have specic needs, many of which are unrealised. The vast
and increased workload, which involved less patient-contact and more non-nursing
duties, came as a surprise to participants in this study. The expectation of in-depth
knowledge, coupled with feelings of increased responsibility and compounded by
relatively little experience did little to ease the transition to becoming a newly
qualied nurse. There is a need to contextualise the transition to registration so
that expectations of newly qualied nurses are realistic. Management and staff must
remain cognisant of the fact that many newly registered nurses have relatively lim-
ited clinical experience at the time of registration.

c
2006 Elsevier Ltd. All rights reserved.
Introduction
The introduction of supernumerary student status
in Ireland in 1994 heralded many changes in nurse
education. By 2007 it will be one decade since new-
ly qualied Irish nurses had supernumerary student
status. Before Irish nursing students were granted
supernumerary status, they formed a large compo-
nent of the workforce and contributed substan-
tially to service (An Bord Altranais, 1994).
Concerns were raised about the quality and quan-
tity of teaching received by these apprenticeship
students (Commission on Nursing, 1998). The intro-
duction of the Diploma in Nursing in Ireland and the
formation of links with Institutes of Higher Educa-
tion were identied as a means by which the prep-
aration of nursing students for practice might be
improved. This paper reports on the clinical expe-
riences of 12 newly qualied general nurses who
had supernumerary student status. The aim of the
study was to ascertain newly qualied Irish nurses
0260-6917/$ - see front matter

c
2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2006.11.003
*
Tel.: +353 1 8963938/8962692; fax: +353 1 6083001.
E-mail address: mooneyma@tcd.ie
Nurse Education Today (2007) 27, 840847
intl.elsevierhealth.com/journals/nedt
Nurse
Education
Today
perceptions of their transition from being a nursing
student to becoming a registered nurse in an Irish
general hospital. No published Irish literature was
sourced on this specic subject.
Literature review
Over the last 30 years the international nursing liter-
ature has highlighted issues concerning the needs of
newly qualied nurses in the clinical setting. Much
of this literature refers to high levels of dissatisfac-
tion and disappointment among newly qualied
nurses whose aspirations are frequently unmet,
resulting in disappointment and frustration (Ger-
rish, 2000; Amos, 2001; Boychuk-Duchscher, 2001;
Whitehead, 2001). Reality Shock, a term coined
by Kramer (1974) endeavours to conjure up the
phases of reaction to the disparity between the post
qualication expectations and the actual reality
encountered by newly qualied nurses. This dispar-
ity between the ideal clinical environment and the
reality relates to high levels of accountability com-
pounded by fear of litigation, which results in pres-
sure and stress at work (Kelly, 1996; Amos, 2001).
Expressions of disappointment by newly regis-
tered nurses originate from limited time availability
for patient care, conicting values between staff
and the institution and unexpected levels of respon-
sibility (Jasper, 1996; White, 1996; Amos, 2001;
Whitehead, 2001; Kilstoff and Rochester, 2004).
Such disappointment can manifest itself in frustra-
tion and demoralisation because of an inability to
provide care to the desired standard (Jasper,
1996). In the initial period following qualication
the need for time to practice skills, adapt to the
new role and gain condence has been recognised
(Boxer and Kluge, 2000; Thomka, 2001). Such oppor-
tunities are determined and often restrained by
environmental factors at clinical level which in-
clude staff shortages, patient acuity and pressures
to meet role expectations (Kramer, 1974; Boy-
chuk-Duchscher, 2001; Evans, 2001). An Irish survey
carried out by the Dublin Academic Teaching Hospi-
tals (2000) revealed that problems relating to staff
shortages, low morale, stress and staff changeover
place increased demand on junior nurses, as they
are expected to take on senior roles and take
responsibility for decision-making soon after quali-
cation. The opportunity for a gradual development
of skills, condence and competence is not there-
fore always available to newly qualied nurses.
Baillie (1999) suggested that the experiences of
newly qualied nurses will be determined some-
what by the expectations and attitudes of the ward
managers to whom they are allocated post quali-
cation. Newly qualied nurses therefore seek
employment in areas that they perceive to be sup-
portive and facilitative (Andrews et al., 2005).
There appears however to be a disparity between
ward managers expectations and the actual per-
formance of newly qualied nurses. Studies have
shown that good knowledge and ability were ele-
mentary, while some managers had expectations
that included an ability to deal with conict and
complaints, mentoring, and group dynamics (Kelly,
1996; Baillie, 1999; Carlisle et al., 1999). Carlisle
et al. (1999) identied that neophyte nurses skills
levels and task-performance abilities were inade-
quate and less than the expectation levels of clini-
cal nurse managers.
Kelly (1996) and Evans (2001) suggest that such
high expectations placed upon newly qualied
nurses and the requirement to act prematurely in
senior roles have resulted in graduates having unre-
alistically high self-expectations.
Despite the expectations of and by new gradu-
ates, the literature has shown that newly qualied
nurses tend to be generally good at acknowledging
their limitations and will openly admit to having
knowledge decits (Jasper, 1996; Maben and Clark,
1998; Gerrish, 2000; Evans, 2001; Ross and Clifford,
2002). It is without question that in all walks of life
change and transition are challenging. However,
the transition to the role of registered nurse from
nursing student is particularly demanding when
that role differs signicantly from what is originally
anticipated, as is suggested in the literature (Kra-
mer, 1974; Jasper, 1996).
The study
Aim
The aim of the study was to ascertain how newly
qualied Irish nurses perceived the transition from
being a supernumerary nursing student to becom-
ing a registered nurse.
Design
A grounded theory approach was adopted to con-
duct this study. The research process was guided
by symbolic interactionism, which is a specic ap-
proach to enquiring about human conduct and
group behaviour (Morse, 2001). Theoretical sam-
pling was employed and the research instruments
included the researcher and a semi-structured
interview guide with open-ended questions. The
Facing registration: The expectations and the unexpected 841
process of sampling, data collection, coding and
analysis were concurrent after the initial inter-
view. Data were handled manually.
Participants
A list of those nurses meeting the inclusion criteria
was provided by the hospital Human Resources
Department. As theoretical sampling was em-
ployed, a small sample was initially chosen from
this list and sampling continued until the end of
the study.
Data collection and Analysis
The study was conducted in an Irish acute general
hospital. Individual semi-structured depth inter-
views were conducted with 12 registered nurses
from two separate cohorts who were within 12
months of qualication. Eleven interviews were
recorded and typed verbatim. At the request of
one participant, notes were the only form of re-
cord taken. Each interview lasted between 38
and 96 min. A feature of grounded theory is the
simultaneous collection, coding and analysis of
data to generate theory about action and interac-
tion, related conditions and consequences (Strauss
and Corbin, 1998).
Theoretical sampling used in grounded theory
and applied to this study refers to sampling on the
basis of emerging concepts. The underlying aim of
theoretical sampling is to explore the varied condi-
tions along which the properties of concepts vary
(Strauss and Corbin, 1998). In an effort to full this
aim, I engaged with participants for long periods,
the interviews were recorded and record-keeping
was systematic and meticulous. The information
sought in each successive interview was pre-deter-
mined by the data and emerging concepts that
had been yielded in the preceding interview. Data
collection, coding, sampling and analysis were con-
current, except during the initial interview.
The exact size of the population for a grounded
theory study cannot be ascertained until the data
are gathered, as the sampling process is controlled
by the emerging data (Glaser and Strauss, 1967).
Sample size and composition are normally deter-
mined by data saturation. While data appeared to
be saturated in this study, the limited sample of
12 participants is insufcient to denitively deter-
mine this. Data analysis began and continued
through each stage of the research process. The
Gibbs reective cycle cited by Johns (2000), as-
sisted with the process of reection on the inter-
views, emerging concepts and analyses. Open
coding began with in vivo codes and microanal-
ysis was employed to ensure a thorough examina-
tion of the data. The codes were then rened
into sub-categories, from which categories were
then developed. This systematic process is known
as axial coding (Polit and Beck, 2006) and involves
the assignment of the somewhat abstract deni-
tions to the open codes. The category groups were
compared to ensure inclusion of all data. A limited
time frame and relatively small sample size pre-
vented progression beyond axial coding.
Rigour
As the research instrument, the researcher must
pay scrupulous attention to data collection meth-
ods to ensure meaningful interpretation of data
(Rew et al., 1993).Within the qualitative paradigm
there are certain steps that should be taken to en-
sure scientic rigor (Rew et al., 1993). Sandelowski
(1986) states that credibility, applicability, consis-
tency and conrmability are four aspects of trust-
worthiness. These criteria were addressed within
this study by means of member checking, method-
ical steps in data analysis, peer assessment and evi-
dence of an audit trail.
Ethical considerations
There is an onus of personal and professional
responsibility on every researcher to ensure that
the design is morally and ethically sound (Streubert
and Carpenter, 1999). The issues of autonomy,
condentiality, respect, consent and anonymity
were upheld in this study.
Ethical approval was granted from the Hospital
Research Ethics Committee. Written and verbal
information was provided about the study. In-
formed consent was sought before and during the
interviews.
Findings
An unexpected reality
This category, entitled An Unexpected Reality
exemplies the unexpected challenges encoun-
tered by newly qualied Irish nurses following reg-
istration. Their role transition involved new and
unexpected changes which only became apparent
when they had qualied. Within the category there
are three sub-categories entitled Great Expecta-
tions, No Time for Nursing and Facing the
Trepidations.
842 M. Mooney
Great expectations
This sub-category represents participants percep-
tions of the expectations placed upon them by
other people. All respondents felt these expecta-
tions were high and sometimes unreasonable. The
expectations were often implicit rather than expli-
cit and originated from managers, doctors, rela-
tives and patients.
Participants suggested that there is an assump-
tion that being qualied means knowing every-
thing. One respondent talked about being on an
orthopaedic ward with little experience of this
speciality and yet felt she should know everything
about orthopaedics. Some ward managers re-en-
forced this perception. One newly qualied nurse
described how the manager on her ward glared at
her when she asked a question, while another
was told that she should no longer need to
ask questions. Participants described being
timed by the ward manager while doing a drug
round.
I was doing the drugs and I was looking up a
drug because I didnt know that drug and the sis-
ter went [participant points to her watch with
arm elevated in the air]. It was to let me know
about how long it was taking me to do the drug
round.
I felt guilty about looking up things that I didnt
know. Thats why I used to only do it [look things
up] on a Saturday or Sunday when the ward sister
was off duty.
The newly qualied nurses felt that they were
sometimes held responsible for things outside their
control. Relatives expected them to be familiar
with all patients, not only those for whom they
were caring. One participant described how dif-
cult it was to return from leave because no allow-
ances were made for decits in information about
patients.
If you are on a ward round and its your rst day
looking after that patient, you are expected to
know whats going on and if something hasnt been
lled in from the previous day or the previous
night, you are held responsible for that.
The expectation by patients also increased fol-
lowing registration. Some patients seemed oblivi-
ous to nurses workloads and expected them to
spend unrealistic amounts of time with them. The
nurses felt responsible for not honouring this
expectation.
As well as trying to meet the expectations of
others, the newly qualied nurses had high self-
expectations. They tried to give the best possible
care and felt guilty when failing to meet every-
ones needs. They were fragile and handled dif-
cult situations differently to senior staff. One
nurse described a contrast between how she
and a senior nurse handled a drug error. The se-
nior nurse accepted the mistake and was very
calm about it but emphasised the doctors role
and responsibility in documenting clear and accu-
rate prescriptions. The newly qualied nurse how-
ever felt that she lost condence when this
incident occurred and engaged in self-blame and
shame.
I freaked out, (silence) oh my God, I am going to
kill everybody.
This sub-category illustrates how ill-prepared
for the reality the newly qualied nurses felt. On
completion of their general nursing education they
were expected to be knowledgeable and compe-
tent. Their self-expectations were high and com-
pounded by those of ward managers, doctors,
patients and relatives.
No time for nursing
This sub-category describes participants accounts
of the unanticipated expanse of their nursing role.
They spoke about the resentment of wasting nurs-
ing time doing non-nursing duties, which reduced
their patient-contact time. This resulted in feelings
of guilt, disappointment and frustration. They
appreciated the importance of sorting patients is-
sues, but resented the fact that this obligation al-
ways lay with nurses.
It drives me mad, I dont see why we should
look them up [blood results] for them [doctors]
and then go running after them asking what are
you going to do about this? That is surely not
our job.
One interviewee described how entire days
could be spent in an ofce trying to contact mul-
ti-disciplinary team members to get patients seen
and to get their problems sorted. This work was
considered unrewarding and was rarely acknowl-
edged as part of the nursing role. Concerns were
raised generally about putting real nursing duties
on the long nger to get through unimportant
and mainly administrative work.
I am talking about things that I wouldnt exactly
call nursing, you know, technical things. Things
that em.., in the past I would have considered to
be the doctors job, not a nurses job.
Facing registration: The expectations and the unexpected 843
Participants described increased workloads
compared with their workloads as pre-registered
or rostered students. Eleven of the 12 nurses
reported that nursing students seemed to have a
better rapport with patients and learned more
about them than staff nurses.
I didnt expect that communication would
decrease at all after qualication but you dont
get time to communicate with patients anymore.
I remember being a student and you would know
everything about them.
There was one deviant case within the two co-
horts. This nurse was on a ward where quality time
with patients was valued and non-nursing duties
were not seen as important. In this area it seemed
that each member of the multi-disciplinary team
had a dened role and each role was equally valued
and fullled. The teaching, facilitation and learn-
ing atmosphere in this clinical area was described
as being very positive. The presence of a deviant
case serves to enhance the overall credibility of
the study ndings.
This sub-category entitled No Time for Nurs-
ing illustrates the changes associated with role
transition of newly qualied nurses. The descrip-
tions of the focus on non-nursing tasks, which con-
sumed real nursing time, resulted in reduced
patient-contact and manifested itself in feelings
of guilt, despair and frustration. All 11 nurses
admitted that they carried out non-nursing duties
for the sake of their patients but disagreed with
it in principle. The ndings from the twelfth nurse
were inconsistent with the above in terms of ward
atmosphere and expected nursing roles.
Facing the trepidations
This sub-category represents the fears and tribula-
tions of newly registered nurses. The respondents
freely articulated their multiple concerns about
post qualication challenges and difculties. These
included unexpected and increased responsibility,
concerns for patient safety and an inability to
incorporate theory and practice. Of these, the
greatest concern was the feeling of unprecedented
responsibility and accountability.
When I am with my friends who arent nurses I
sometimes wish I was like them; that I was oblivi-
ous to what goes on in hospitals. They dont have
the responsibility that I have. I think Im a bit young
to be responsible for so many patients.
Each respondent expressed concerns about drug
administration. They felt unable to match their
theoretical and practical pharmacology informa-
tion. Only a minority of the participants had com-
pleted an entire drug administration round, as a
nursing student, with a qualied nurse. Conse-
quently their difculties arose from fear and
inexperience.
The drugs terrify me. As students we didnt have
much exposure to the drugs. I denitely wouldnt
do a drug round on my own, without a staff nurse,
even though I am qualied.
Participants expressed surprise at the manner in
which drug errors were handled on the wards. Many
drug errors went unreported and newly registered
nurses were discouraged from reporting drug errors
by senior nurses. One nurse suggested that this
avoidance was secondary to the traditional puni-
tive treatment of staff. The disclosure of many
cover-ups was a startling discovery for partici-
pants. One respondent expressed fears for patient
safety after she witnessed a serious drug adminis-
tration incident by two senior staff nurses.
I dont think there is any of us that havent made
drug errors. But they [drug errors] denitely just go
unreported. If you made a mistake and said it,
theyd [senior staff] tell you, oh dont worry about
it.
One respondent described how she perceived a
dilemma in becoming more senior. For this nurse
seniority was associated with increased condence
but also with less concern about nursing duties. She
looked forward to the increase in condence that
seemed to be associated with seniority but was
uncomfortable with the potential diminution of
concern.
From what I can see, people who are qualied
longer seem to be less affected by things. I am con-
stantly worrying about my patients. I never want to
stop worrying that they are okay, or get to a stage
where I am not worried about them.
This sub-category summarises the unexpected
problems that faced participants following regis-
tration. The concerns were related to their own
abilities and the abilities of other nurses to compe-
tently deliver patient care. While participants had
concerns about inexperience, accountability and
knowledge decits, their most specic concerns re-
lated to drug administration issues. The deviant
case in this study did not fear accountability or
responsibility. She did however voice concerns
about limited drug knowledge and medication
administration.
The three sub-categories comprised the over-
arching category called an Unexpected Real-
ity. While the newly qualied nurses felt more
844 M. Mooney
prepared for the role transition at the end of the
rostered placement, they were further con-
fronted with unexpected challenges when they
qualied. Their role extended beyond their
expectation when they realised new worries con-
cerning patient care and safety. They were faced
with administering drugs, isolated decision-mak-
ing and attempts to meet the unrealistic expec-
tations of themselves and others. Participants
had not perceived that the transition to the role
of qualied nurse would be so problematic. Their
expectations were far removed from the reality.
Discussion
The nurses in this Irish study were concerned with
the lack of time available for patient care. The
international literature suggests that other newly
qualied nurses have similar concerns (White,
1996; Charnley, 1999; Gerrish, 2000; Whitehead,
2001; Kilstoff and Rochester, 2004). Newly quali-
ed nurses have reported feelings of guilt, resent-
ment, disappointment and frustration because of
their inability to spent adequate time with patients
and provide the desired standards of care (Charn-
ley, 1999; Jasper, 1996; Kapborg and Fischbein,
1998).
Wheeler et al. (2000) suggested that staff short-
ages were one of the primary difculties encoun-
tered by nurses, which resulted in reduced
support, high attrition rates and burnout. It has
been acknowledged that adverse patient outcomes
are less likely when stafng levels in nursing are
high (Needleman et al., 2002; Rochester et al.,
2005). This positive correlation between staff
nurse shortages and increased incidences of pa-
tient adversities serves only to increase pressures
on neophyte registered nurses. Rosser and King
(2003) remind readers that the transition of new
nurses impacts upon all staff. If staff shortages
are a problem then ward managers may be forced,
without alternative to place newly qualied nurses
in senior positions in order to meet service needs.
This has implications for the current study, partic-
ularly where newly qualied nurses felt obliged to
full the role of senior nurse. It is acknowledged
that a scarcity of registered nurses has meant that
newly qualied nurses are expected to take on in-
creased responsibility prematurely (The Dublin
Academic Teaching Hospitals, 2000; Wheeler
et al., 2000; Casey et al., 2004; Bates, 2005).
The difculties associated with unprecedented
responsibility and accountability have been identi-
ed in this study and by other researchers (White,
1996; Gerrish, 2000; Whitehead, 2001; McKenna
et al., 2003). These difculties were attributed to
the sheltered student life (Charnley, 1999; White-
head, 2001), a lack of clinical experience (Baillie,
1999) and a busy clinical environment. Wheeler
et al. (2000) identied that junior staff nurses
struggled and erred because senior staff nurses
were reluctant to help or get involved. This nding
was echoed by participants in this study. The man-
agement and administration of medications was
raised by almost all participants as being a specic
problem post qualication. This concern has also
been highlighted in the literature (Manias and Bull-
ock, 2002; Grandell-Niemi et al., 2005; Manias
et al., 2005).
Researchers (Baillie, 1999; Carlisle et al., 1999;
Evans, 2001) suggested that newly qualied nurses
high self-expectations originated from those expec-
tations implied or asserted by ward managers. One
such expectation was the ability to t in personally
and professionally (Baillie, 1999; Carlisle et al.,
1999). According to Melia (1987) nurses learn from
unspoken messages which lead to tting in and sur-
viving. While participants in the current study did
not refer explicitly to the expectations placed upon
them by ward managers, this was implied in their
descriptions of being timed during medication
rounds and being afraid to ask questions. Most of
the 12 respondents had high self-expectations and
tried to cope without looking for help. Other studies
have identied that newly qualied nurses have
unrealistic self-expectations (Kelly, 1996; Charn-
ley, 1999; Evans, 2001) and some admitted to work-
ing twice as hard as others in an effort to prove
themselves capable as nurses (Kelly, 1996). While
this study reports on the perspectives of two sepa-
rate cohorts of newly qualied nurses, both were
taken from the same setting which limits how the
ndings might be generalised. However, these re-
search ndings are consistent with the international
literature and highlight that similar problems exist
in the Irish context as in other settings. The chal-
lenge that now lies ahead for all stakeholders is
how to effectively improve future conditions for
newly qualied nurses.
Conclusion
The Dublin Academic Teaching Hospitals (2000) has
promoted the support of newly qualied nurses,
yet the current study revealed that this concept
has failed. These ndings are consistent with other
international studies. The development of skills
and condence for newly qualied nurses is deter-
mined by several factors including stafng levels,
patient acuity and stress related to fears of
Facing registration: The expectations and the unexpected 845
accountability and responsibility. Furthermore the
expectations from neophyte nurses are at times
unrealistic (Kelly, 1996; Thomka, 2001). Such
expectations include pressures to adapt quickly,
conform to ward routines, integrate well with
other staff and accept senior nursing responsibili-
ties prematurely (Kelly, 1996; Carlisle et al.,
1999; Baillie, 1999). These pressures are often
compounded by the unrealistic expectations that
newly qualied nurses place upon themselves to
perfect their work and be adept in knowledge and
skills (Kelly, 1996; Evans, 2001). The ndings and
discussion above suggest that newly qualied
nurses who had supernumerary student status are
not adequately prepared for the changes associ-
ated with the transition from being a student to
becoming a registered nurse.
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