Transition shock is a relatively new term based on reality shock, coined by Marlene Kramer in her 1974 book, Reality Shock: Why Nurses Leave Nursing. Transition shock theory is a result of work by Dr Judy Duchscher who’s research into this phenomenon spans over a decade.

What is transition shock?

Based on reality shock (and culture shock), transition shock describes the transitional period that a student nurse may experience when beginning their career as a registered nurse. It is a combination of ‘transition’ (the process of changing from being a student to participating as a registered nurse) and ‘shock’ (the sudden upsetting or surprising experience relating to the role).

Stages of reality shock

The stages of reality shock include the honeymoon phase, shock phase, recovery phase and finally, the resolution phase.

Honeymoon phase – this phase is a period of excitement as graduates see an idealised version of the role of registered nurse and are eager to learn as much as possible.

Shock phase – this phase is characterised by feelings of negativity towards the role as the responsibilities and day-to-day tasks don’t resemble the idealised version in the honeymoon phase.

Recovery phase – the recovery phase begins the upwards climb towards greater positivity where expectations and realities are more balanced.

Resolution phase – resolution is the fourth and final stage of reality shock and usually occurs at the one-year mark. Nurses begin to have perspective and can contribute more wholly to the profession.


Stages of transition shock

Dr Duchscher’s transition shock model goes beyond the professional elements of this experience and includes three stages – doing, being and knowing.

In research, Dr Duchscher demonstrates that a registered nurse engaging in professional practice for the first time will encounter a broad range of physical, intellectual, emotional, developmental and sociocultural changes.

It is the contrast between the relationships, roles, responsibilities, knowledge and performance expectations in an academic environment with those in the professional setting that lead to transition shock.

Stage 1 – Doing

The first three to four months can be exciting and overwhelming as nurses adjust from a structured and relatively predictable educational environment to professional nursing responsibilities.

The learning curve is steep at this stage. Nurses can experience performance anxiety and self-doubt as they discover unfamiliar areas of professional practice.  They can also become burdened with a workload that is at odds with their capabilities due to inexperience with setting boundaries and limitations related to their responsibilities.

Stage 2 – Being

This phase encompasses the next four to five months and is dominated by rapid advancement in a nurse’s thinking, knowledge and skill competency. They gain a level of comfort in their role but are confronted with inadequacies in the healthcare system. At this stage, there may be a crisis of confidence as greater responsibilities are thrust upon them, and fear of rejection (declining workload due to limitations) and anxiety builds.

Stage 3 – Knowing

The third and final stage of the transition shock model is when newly registered nurses begin to feel a separation between themselves and other practitioners. They see themselves as professionals able to practice independently. However, this stage may see dissatisfaction with work/life balance, shift work and work environment. Colleagues and will be crucial in helping nurses find purpose in their work, which will either galvanise or alienate them within the workplace.

Research shows that most nurses will experience transition shock, but many factors influence positive or negative outcomes.

Former nurse turned educator Sarah Morse says many factors will influence whether a nurse will succeed or burn out during this early stage.

“The support given to new graduates can be impacted by the work culture around them, increased patient load for nursing staff, lack of senior nurses, nurses and health professionals who are burnt out, and lack of specific clinical training for that specialty area for the new graduate.

“I heard of one facility recently where a large majority of senior nurses left due to a pay dispute, which left new graduates in charge of shifts and running the ward.

“This led to increased errors, and in one case missing allocating a patient for an entire shift, which had very negative health outcomes for the patient.”

A registered nurse for 30 years, Caroline Dawson, now a trainer and educator, says her hospital-based training did not lead to transition shock.

“The first ten weeks of training were classroom-based at hospitals. We learned all the basics, like how to make beds, do bed baths, communicate with patients, give injections, help patients use bedpans, about infection control – basically the grassroots of nursing!

“We then moved onto speciality areas – medical, surgical, paediatrics, theatre, community, psychiatry …and some modules were repeated as night shift experience.”

For every one week in the classroom, there was ten weeks’ experience on a specific ward followed by consolidation and feedback, says Ms Dawson.

“Due to our extensive clinical on-the-job experiences, exams were just a formality. The only change was a uniform and adapting to a new ward if going onto a permanent position.

“I didn’t go through transition shock because there was little transition to be made. We had the basic knowledge and experience to apply to any nursing situation.”

As a community nurse training graduates, Ms Dawson says she witnessed many new nurses struggling with adjusting to professional practice following university.

“What surprised me was the students’ lack of confidence at that stage and basic lack of skills.

“I was surprised to have to guide them through giving an injection, even though they said they were trained in it already.

“I asked students about their graduate year, and in the majority of cases, they said they were scared or not prepared.

“It astounded me. I can only remember one graduate nurse who felt ready, but she was quite confident and mature beyond her years.”

A university-educated graduate nurse may also feel that less complex tasks are beneath them, which can be problematic, explained Ms Dawson.

“Clients in the community would often share their hospital experiences with me. Many said some of the younger nurses wouldn’t help them in certain circumstances, especially when the task was deemed menial.

“Nursing is a true vocation. It’s unique with nurses being intermediaries between doctors – tasks range from menial to technical such as monitoring equipment. It requires substantial communication skills…most of nursing should be about caring and nurturing the most vulnerable.”

The in-hospital training and education Ms Dawson received in her transition to registered nurse was expected – not dramatic.

“I didn’t feel isolated because I was used to working alongside other nurses at different levels of experience.

“I knew who I could trust and didn’t let limiting beliefs get in the way. I always found that person, probably because we had all been hospital-based trained and had strong comradery.

“Entering into the graduate year without enough experience can certainly predispose new nurses to shock moments.

“Registered nurse training appears, from all the evidence, to have gone from one extreme to the other – hospital-based to a university degree.

“It makes sense that some adjustments need to be made, so nurses are more prepared in the transition to the graduate year.”