1 Sara Stojčević
1 Marija Ljubičić
1,2Sonja Šare
1 Ivana Gusar
1 University of Zadar, Department of Health Studies, Zadar, Croatia
2 Ante Kuzmanić Medical School, Zadar, Croatia Article received: 18. 09. 2025.
Article accepted: 10. 11. 2025.
DOI: 10.24141/2/10/1/13
Author for correspondence:
Ivana Gusar
University of Zadar, Department of Health Studies, Zadar,
Croatia
Keywords: employed, transition, nurses, adaptation, stre- ss, mentoring, work environment
Employment after completing formal education pre- sents a challenge for every individual, particularly due to the adaptation process (1–3), which is not lin- ear and requires continuous confrontation with new obstacles (4). For certain professions, such as nurs- ing, this adaptation can be especially demanding. As early as 1974, Marlene Kramer described inadequate adjustment to a new work environment using the term “reality shock” (5). Kramer defines a state that occurs when expectations regarding a new profes- sional role significantly diverge from reality (5). This phenomenon often leads to leaving a workplace or even the profession itself (6), and some studies re- port that between 30–70% of nurses express an in- tention to leave the profession within the first few years of practice (7, 8). Stress, interpersonal relation- ships, a sense of not belonging, and a lack of skills have been identified as key contributing factors (6, 9), while some research points to the increasingly complex nature of the problem (10–12). According to the World Health Organization (13), there is currently a global shortage of approximately 6 million nurses, a number that is projected to rise to 13 million by 2030. In Croatia alone, there is a shortage of around 4,000 nurses (14). In addition to these consequences, real- ity shock also contributes to a shortened career span of employees (5). Judy Duchscher’s model of transi- tion shock outlines that newly employed nurses typi- cally go through three main phases: the honeymoon phase, lasting approximately the first three to four months. It is characterized by enthusiasm and opti- mism, accompanied by a limited understanding of the actual challenges of the profession. The shock or cri- sis phase, usually occurring between the fourth and fifth month, is marked by a discrepancy between ex- pectations and reality, often accompanied by stress, professional burnout, and doubts about the decision to pursue the profession. The resolution phase, gen- erally lasting until the twelfth month of employment, during which newly employed nurses develop coping strategies, regain enthusiasm and self-confidence, and begin to progress professionally (4). However, the author also emphasizes that the adaptation pro- cess is not linear, and regressions between phases are possible. Stable interpersonal relationships, appropriate work assignments, support from col-
leagues and supervisors, as well as opportunities for professional development, increase the likeli- hood of a healthy transition into clinical practice (4). Although they possess formal competencies, newly employed nurses often feel unprepared for their new role, which can undermine their self-confidence and performance in carrying out professional duties (15). Discrepancies between expectations and the actual level of responsibility contribute to stress, which fre- quently leads to leaving the workplace or even the profession altogether (15–17). The most common challenges include unrealistic expectations from col- leagues, conflicts in professional values, fear of fail- ure, and a lack of support (6). The first few months of employment are typically characterized by a focus on personal learning and performing tasks delegated by others, reliance on theoretical knowledge, and fear of making independent decisions (16, 17). However, after two to three months, nurses generally begin to develop critical thinking skills and the ability to plan care independently, while after five to six months, they are usually able to provide comprehensive, ho- listic, and individualized nursing care (15, 16).
Appropriate support for nurses during their transi- tion is crucial, especially given the ongoing shortage of nurses in the healthcare system, which increases pressure on new and experienced staff. Clearly, in- formation about challenges and strategies can be helpful to reduce the transition shock, current high turnover rates among nurses, and ensure the long- term sustainability of the healthcare system.
This paper aims to identify the main challenges faced by newly employed nurses during the transition to clinical practice and to summarize strategies used to facilitate adaptation.
This manuscript is based on a narrative review of literature addressing the adaptation of newly em- ployed nurses to clinical practice and the phenom- enon of transition shock.
Relevant sources were identified through a search of available publications in databases. As this study is based on a narrative review, the available literature was analyzed using a combination of key terms re- lated to topic, without imposing formal restrictions on specific databases using keywords such as: newly employed nurses, transition shock, nurse adaptation, challenges, and strategies.
Inclusion criteria were: published in peer-reviewed journals, written in English, focused on experiences of newly employed nurses or nurses in new clinical environments, and addressing challenges and strat- egies related to transition shock. Studies were ex- cluded if they did not meet these criteria or were not accessible in full text. Data from the included studies were analyzed thematically, identifying major themes and patterns related to challenges and strategies in the transition process. Findings were interpreted in the context of relevant literature. Although this is a narrative review, this search strategy, clearly defined inclusion/exclusion criteria, and thematic synthesis aim to enhance the transparency of the review. The selection of sources was guided by their relevance to the topic. Priority was given to studies that dis-
cles, and communication challenges with physicians. Various strategies have been proposed to mitigate these issues, such as structured orientation pro- grams, mentoring, fostering a supportive work envi- ronment, providing regular feedback, and implement- ing stress management interventions. Importantly, transition shock is not limited to newly employed nurses; evidence suggests that even experienced nurses may encounter similar difficulties when ex- posed to new or particularly stressful working con- ditions, such as those arising during the COVID-19 pandemic. Identified challenges and strategies are summarized in Table 1.
Table 1. Challenges and Strategies | |
Challenges | Strategies |
Lack of self-confidence | Structured orientation programs |
Relationships with colleagues | Mentorship |
Independence | Healthy work environment |
Work environment | feedback |
Organization and prioritization skills | Stress management |
Communication with physicians | |
Transition shock in new work conditions | |
cuss the experiences of newly employed nurses or experienced nurses working in new and/or stressful
environments, as well as those describing challenges
and strategies related to transition shock.
The review reveals that newly employed nurses com- monly face several significant challenges, including low self-confidence, difficulties in building collegial relationships, limited professional autonomy, de- manding work environments, organizational obsta-
The aim of this paper was to identify the main chal- lenges faced by newly employed nurses during the transition to clinical practice and to summarize strat- egies used to facilitate adaptation. Many challenges have been found in the literature that accompany this period, such as: lack of self-confidence, inde- pendence, and relationships with team members. In addition, the literature cites difficulties experienced nurses face when changing jobs. Structured orienta- tion, mentorship, healthy work environments, feed- back, and stress management consistently improve adaptation outcomes and reduce transition shock.
The adaptation period for newly employed nurses typically lasts around 12 months, with the signs and effects of adjustment generally diminishing after approximately six months (15, 16). Nevertheless, even within this relatively short period, the rate of attrition from the profession can be significant (7, 8). Researchers have sought to categorize the factors that hinder this transition to develop effective solu- tions. One of the key contributions to understand- ing this phenomenon was provided by the research of Casey et al., who, using open-ended questions, identified six major challenges (18). These findings, including lack of self-confidence, difficulties in rela- tionships with colleagues, limited independence, and challenges associated with the work environment, are not unique to a single region but have also been corroborated by studies conducted in Croatia (3, 6, 9). The consistency of these findings, regardless of geographical location, highlights the universal nature of transitional shock and underscores the need for global solutions.
Lack of Self-Confidence
Professional self-confidence is a key attribute for newly employed nurses (19). While formal education provides only the foundation, the workplace environ- ment often demands a high level of independence and competence. Newly employed nurses frequently ex- perience a perceived gap between theoretical knowl- edge and clinical practice, which further contributes to diminished self-confidence (20, 21). Ortiz identified seven factors that influence self-confidence: effective communication, making mistakes, the theory–practice gap, independence, interpersonal relationships, posi- tive feedback, and experience (20). Negative events, such as errors in patient care and treatment, can significantly undermine self-confidence and lead to stress and anxiety (20). Conversely, positive feedback and experience substantially enhance professional self-confidence, increasing motivation and commit- ment to the profession (20).
Relationships with Colleagues
A sense of belonging within the workplace and the healthcare team has a positive impact on feelings of safety, self-confidence, and overall effectiveness
(22). Nurses who develop supportive and collegial
relationships at work tend to acquire new profes- sional knowledge more quickly and feel emotion- ally supported, whereas poor relationships increase stress and anxiety and hinder the transition into the profession (23–25). On the other hand, positive relationships with colleagues and physicians can mitigate the negative effects of transition shock and strengthen the self-confidence of newly employed nurses (6, 20).
Independence
The transition from education to an autonomous pro- fessional role requires and entails assuming responsi- bility and making independent decisions. Conversely, a lack of independence in the early stages of employ- ment can lead to feelings of being overwhelmed and increased anxiety, whereas achieving autonomy fos- ters professional satisfaction and strengthens self- confidence (18) which is a key attribute for newly employed nurses (19).
Work Environment
The adaptation of newly employed nurses is influ- enced by both the physical and organizational work environment, which includes factors such as shift length (8–12 hours, day/night), nurse-to-patient ratios, and the availability of equipment and medi- cations (18). Twelve-hour shifts contribute to in- creased fatigue, while chronic understaffing inten- sifies workload and stress. Furthermore, extended shifts can contribute to work-family conflict, which affects social relationships and overall quality of life
(26). Employees also report feelings of fatigue and cognitive impairment, which can exacerbate mental health problems (27). Positive work environments that encourage autonomy and collaboration are as- sociated with greater job satisfaction, while negative experiences can lead to burnout and exhaustion (28).
Organization and Prioritization Skills
Newly employed nurses initially experience difficul- ties in establishing work routines and setting priori- ties, which significantly prolongs the time required to complete tasks and generates stress. Newly gradu- ated nurses struggle with prioritization due to limited clinical experience, which is critical for effective deci- sion-making in fast-paced environments (29). In this
sense, the mentoring process is of great importance, as mentors, through their knowledge and experience, can facilitate the understanding of work organization and assist in setting appropriate priorities (30). After 8–12 months, their organizational skills improve con- siderably (18).
Communication with Physicians
Effective communication with physicians is crucial for patient safety and the professional develop- ment of nurses. During the first six months, newly employed nurses are often uncertain about how to communicate appropriately with physicians or which physician to contact in specific situations. Over time, these barriers are gradually overcome (18). Newly employed nurses often face challenges such as dif- ficulty asserting themselves, lack of clarity in com- munication, and feelings of undervaluation compared to physicians, which can lead to unresolved disagree- ments and hinder effective collaboration in patient care (31).
Challenges to the adaptation of newly employed nurses induce stress, feelings of being overwhelmed, and reduced professional self-confidence, which in turn increase the intention to leave the profession. Research has identified potential strategies to miti- gate these barriers, including enhanced communica- tion with mentors, structured orientation programs, emotional support, timely feedback, stress manage- ment, and continuing education (32).
Structured Orientation Programs
Orientation programs begin with an introduction to the new role, followed by familiarization with the institution’s mission, values, and organizational cul- ture, which helps newcomers align with workplace goals (32). These programs refresh essential nursing skills (patient assessment, medication administration, wound care, infection control) and include workshops on interpersonal collaboration. They also define team members’ roles and responsibilities, promote a multi- disciplinary approach, and empower newly employed nurses to integrate effectively into the team (32). Orientation programs that focus on socializing new employees into the organizational culture can lead to higher levels of engagement (33).
Mentorship
Mentorship programs reduce the intention to leave the profession and increase job satisfaction (30, 34). Mentors assist in applying theoretical knowledge, alleviating stress, and building self-confidence. Pro- grams are typically conducted on a one-to-one basis and include observation, skill demonstration, discus- sion, reflection, and the development of interper- sonal skills (30). Evaluations indicate reduced turno- ver intentions, improved nursing competencies, skill enhancement, and higher job satisfaction (30). By providing support and guidance, mentoring increases job satisfaction and helps new nurses feel more in- tegrated and valued within their organizations, mak- ing it an effective strategy for retaining nursing staff
(35). Effective mentoring provides essential support, guidance and opportunities for continuous profes- sional development (36).
Healthy Work Environment
A healthy work environment supports both nurses and patients. A healthy environment reduces nurse burnout, which in turn positively impacts patient care and outcomes (37). Standards include effective professional communication, genuine collaboration, sound decision-making, adequate nurse staffing, mu- tual respect, and strong leadership. Strong leadership, characterized by transparency, integrity, empathy, and adaptability, has a positive influence on interpersonal relationships and workplace policies (38). Newly em- ployed nurses in supportive work environments learn more quickly and bridge the theory–practice gap more effectively. A systematic review showed that a good work environment leads to fewer patient complica- tions and improved quality of care (37). Therefore, a positive and supportive work environment in health- care has been shown to contribute to safer practices and enhanced quality of patient care.
Feedback
Constructive and timely feedback is essential for newly qualified nurses as it significantly increases their confidence, motivation, and professional satis- faction. Effective feedback fosters a supportive learn- ing environment, enabling nurses to self-assess their skills and identify areas for improvement, which is essential for their professional growth (39). A lack of feedback can reduce self-confidence and prolong the
adaptation period. Reasons for absent feedback often include insufficient mentor competence, an unsup- portive work environment, or a lack of time. In such cir- cumstances, seeking feedback from other colleagues or changing mentors is recommended (38). Although the importance of feedback is well-recognized, its practical implementation often falls short of the ideal. This deficiency can be ascribed to a combination of organizational and individual factors, such as limited mentor competence, insufficient support within the workplace, and time-related constraints.
Stress Management
Stress is inevitable, therefore, it is essential to de- velop coping strategies. Mechanisms include control- ling and preventing stressful situations, seeking help and support, regulating personal reactions, avoiding specific situations, and relying on faith or relaxa- tion techniques (40). Controlling situations involves heightened attention, supervision, double-checking, and consultation with more experienced colleagues. Psychological support and self-directed strategies
Finally, the intensity and nature of transition shock vary according to workplace conditions, support sys- tems, and individual nurse characteristics. The find- ings underscore that interventions should address both individual and organizational factors to mitigate stress and improve adaptation. Surely, the effective- ness of mentioned strategies depends on institu- tional context, availability of resources, and qual- ity of implementation. Tailored interventions appear most effective, highlighting the need for flexible and context-sensitive approaches in practice.
Despite presenting important information, this tradi- tional narrative review did not include a systematic literature review, which could have influenced the author’s subjectivity in the selection of literature. Therefore, in future research, it is planned to apply a systematic review of the literature as well as a com- bination of qualitative and quantitative approaches, which would ensure a deeper insight into the present circumstances.
(exercise, recreation, positive thinking) are crucial for reducing the negative impact of stress and facilitat-
ing the transition (41).
Previous research has predominantly studied the oc- currence of transition shock in newly employed nurses moving from the role of student or trainee to that of a professional worker. The main contributing factor is novelty, which includes a new work environment, col- leagues, and job tasks. However, novelty can also trig- ger transition shock in experienced nurses (9). A 2023 study conducted during the COVID-19 pandemic (9) demonstrated that transferring nurses to COVID-19 wards induced transition shock even in those with prior professional experience. The results indicated that, regardless of gender, marital status, education, or length of work experience, personal and professional stressors were positively correlated with the level of transition shock. Age and gender were associated with a greater perception of transition shock and a higher intention among nurses to leave the profession (9). These findings suggest that transition shock is not limited to the transition from education to professional practice but can also occur in the context of workplace changes within the same profession, highlighting the need for further research on its prevalence.
Newly employed nurses face multiple challenges during the transition to professional practice, includ- ing low self-confidence, difficulties in workplace relationships, limited autonomy, and organizational obstacles. Strategies such as structured orientation programs, mentorship, supportive work environ- ments, timely feedback, and stress management con- sistently facilitate adaptation. Transition shock can affect both new and experienced nurses, particularly in novel or high-stress conditions. Tailored interven- tions addressing both organizational and individual factors are critical for improving nurse adaptation, satisfaction, and retention.
Conceptualization and methodology (SS, IG); data cu- ration and formal analysis (SS, MLJ, SŠ, IG); investiga- tion and project administration (SS, MLJ, SŠ, IG); and writing – original draft and review & editing (SS, MLJ, SŠ, IG). All authors have approved the final manu- script.
The authors declare no conflicts of interest.
Not applicable.
This research did not receive any specific grant from funding agencies in the public, commercial, or not- for-profit sectors.
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