Even though it has been 40 years since Kremer [1] wrote her book about reality shock, making a smooth transition from student to nurse remains an important issue attended by certain difficulties. The difficulties are partially caused by the NGN’s lack of clinical experience and skills when working in acute care hospitals that require a high level of acuity and in which patient care is often complex [2]. The gap between NGNs’ clinical competency and knowledge and the skills needed for clinical practice is an issue not confined to Japan [3, 4]. For the transition to be accomplished successfully, it is important for NGNs to integrate into their clinical units. According to the American Organization of Nurse Executives (AONE) guiding principles to aid the NGNs’ integration into a practice setting, the nurse manager is the key person for ensuring that NGNs succeed in their endeavors [5]. However, little study on how nurse managers help NGNs to integrate into their clinical units has been conducted.

Therefore, this study aimed to identify what kinds of strategies nurse managers use to facilitate the integration of NGNs into clinical units. Adapting the definition of organizational socialization formulated by Van Maanen and Schein [6] in this study, “integration into their clinical unit” is defined as the process by which a NGN acquires the attitudes, behavior, and knowledge needed to be a member of the unit.

The Japanese Nursing Association conducted surveys to ascertain why NGNs leave their job within their first year [7]. The deans or chiefs of nursing schools responded to the survey. The top three factors that made it difficult for NGNs to continue working were a gap between the competencies acquired while at nursing school and the competencies actually needed in the workplace, lack of maturity and resilience among the present generation of young people, and the requirement that a higher standard of competency than before be met. The nursing directors at hospitals also responded to the same question. The top three factors that made continuation difficult were identical. In the same survey, NGNs responded to a question about what caused them distress as a nurse. About 80% answered that they did not have sufficient knowledge and skills to work at their clinical unit. The second source of distress was the anxiety associated with making medical errors. These experiences of Japanese NGNs are reflected in other countries [3, 8, 9].

Successfully making the transition from student to registered nurse is an important issue for NGNs because NGNs’ integration into a clinical unit happens as a result of this transition. Some strategies were reported as being useful in assisting NGNs to make this role transition. As a hospital level approach, the national post-baccalaureate nursing residency program in the U.S. and the graduate nursing program in Australia are well known. As a clinical unit level approach, using a questionnaire survey, Scott et al. [10] identified that orientation programs play a critical role in job satisfaction and retention of NGNs. Creating a specially designed orientation program that takes into account the expectations of both the hospital and NGNs was reported to be an effective way of facilitating the transition from student to nurse [11]. Furthermore, the effectiveness of preceptorship to bridge the gap between being a student to fulfilling the role of a nurse has been documented [12]. The mentoring program in an operating room reduced the turnover rate of newly hired nurses by helping their integration into the practice environment [13]. Taking these strategies together, nurse managers play an important part in helping NGNs to integrate into clinical units. The integration of NGNs into a clinical unit has impact on not only NGNs’ job satisfaction but also on all nurses in the unit and eventually it influences the quality of care provided in the unit.

In Japan, the voluntary turnover rate for first-year nurses in 2011 was 7.5%, which was lower than the previous year [19]. Clinical training for NGNs was encouraged under new legislation from April 2010; therefore, many hospitals started or improved their training programs. While this could have been a factor contributing to the lower turnover rate, the endeavors of nurse managers to integrate NGNs into clinical units may have also have had an influence.

In order to facilitate NGNs’ integration into the clinical unit, the nurse managers used a total of 6 strategies. The three strategies that were standard practice if NGNs were working in clinical units comprise understanding the circumstances of NGNs, providing opportunities for experience and learning, and providing support to nurses who teach NGNs. Regarding understanding the circumstances of NGNs, the nurse managers collected information about how NGNs were working from preceptors and staff nurses in order to gain a clear understanding of their situation. This strategy is vital to providing appropriate and timely support for NGNs in clinical units, and has a strong influence on NGNs’ transition into practice and integration into the workplace [20]. It is imperative to provide NGNs with opportunities for experience and learning by working together in clinical units. While teaching NGNs, the nurse managers supported nurses who teach NGNs by giving them advice and motivating them in their teaching role. These 3 strategies make a meaningful contribution to NGNs’ integration into clinical units; however, it is difficult to effectively facilitate such integration by these strategies alone.

The other 3 strategies that were particularly important were: facilitating self-learning, promoting awareness of being a nurse in the clinical unit, and strengthening the sense of comradeship in clinical units. To facilitate integration, it is essential for NGNs to acquire the knowledge and skills specific to the unit; therefore, nurse managers tried to facilitate self-learning of NGNs by providing opportunities for experience and learning. Salt et al. [21] reviewed articles to find organizational strategies that increase the retention rates of NGNs. One of the strategies identified was a program designed to develop specific clinical skills through such means as classroom instruction, observational experiences, case studies, and computer-based training.

The nurse managers could use methods, such as study sessions to address the specific skills needed in a particular unit, and debriefing sessions after stressful events such as emergency resuscitations [22] would be useful to expand NGNs’ experience and learning opportunities. These opportunities should facilitate NGNs’ self-learning. How willing NGNs are to exercise their clinical skills is affected by how they see themselves as members of the clinical unit [23]; therefore, to give NGNs the confidence to put their clinical skills into practice it is imperative for them to be integrated into their respective units.

In this study, 8 clinical units out of 9 had advisors for preceptors. The preceptor’s role is to support socialization and facilitate the transition of NGNs into practice [24]. By contrast, the advisor’s role is close to that of a mentor’s in the U.S. They serve as a role model, teacher, coach, guide, and compensator for poor preceptor relationships [25]. The advisors were used as part of the preceptorship team to reduce the burden on preceptors and provide the NGNs with the most appropriate support in the clinical unit in the manner suggested by Beecroft et al. [26]. The preceptors’ advisor was a nurse who had more experience than the preceptors; however, they usually did not have any special training on being an advisor. As the position of unit-based staff development specialist in charge of education in a clinical unit does not exist in Japan, nurse managers have to undertake the role of staff development specialist such as coach, facilitator, mentor, and consultant [11]. However, the nurse managers have limited time to fully master the specialist role of staff development. Training for preceptors and advisors is necessary to facilitate NGNs’ integration into a clinical unit.

Clare and van Loon [27] identified best practice principles for the transition from a student to a registered nurse. Both NGNs and their employers recognized that the key issue for NGNs’ positive transition was to genuinely welcome the NGNs and make them feel a part of the nursing team. The nurse managers themselves and other nurses expressed their feeling of welcome to NGNs and acknowledged NGNs’ achievements in patient care. These actions are meaningful in terms of a NGN’s sense that he or she has been accepted as a member of the unit.

NGNs’ sense of belonging to their unit and feeling a part of unit culture were important for their integration into a clinical unit [3]. The study participants gave the NGNs roles to promote their awareness of being a nurse in their unit. This strategy could help to create sense of belonging, which helps the integration of NGNs. Recognition of the contribution that NGNs make to their clinical unit is essential for them to gain a feeling of being important [23]. Levett-Jones and Lathlean [28] indicated that belongingness relates to an individual’s feeling of being secure, accepted, included, valued, and respected by a defined group. As one participant explained, all members of her unit celebrated a patient’s discharge by giving them a colorful piece of origami. This practice helps to create the feeling of “being part of a collegial community” [23]. Wishing NGNs “happy birthday” is another way to promote this feeling. Fostering the sense of belonging is one way to promote comradeship, which in turn creates the sense of a collective purpose and the mentality that we are “in-it together” [29].

As a result of a literature review, Murphy and Sharp [30] found that perceptions of comradeship and peer communication were related to unit cohesion. The nurse managers’ efforts to strengthen the sense of comradeship could make their units more cohesive. This environment should help NGNs to integrate into their clinical units. The Japanese in particular place a high value on the relatedness of individuals and the maintenance of harmony within the group [31]. Therefore, the strategy of strengthening the sense of comradeship in clinical units is central to facilitating the integration of NGNs in the Japanese cultural context.

This strategy, the strengthening of the sense of comradeship, also contributes to the creation of a supportive environment for NGNs, which is a significant component of NGNs’ experience [32]. Miller [33] identified the dimensions of a supportive environment as consisting of team work, cohesiveness and shared values. Directors of nursing recommended the nurse managers for this study because they assumed that the nurses in their units were working together cohesively. These clinical units provide a supportive environment because of the nurse managers’ endeavors to strengthen the sense of comradeship for both NGNs and other nurses.

Although there is a positive correlation between the initial orientation and job satisfaction and retention, the operational definition of orientation varies [10]. In Japan, unit orientation, which is usually the period during which NGNs are not assigned to a patient, is generally short, only one to three days. Even after NGNs are assigned to patients, there should be some form of ongoing orientation. A clearer definition of unit orientation and a plan for ongoing training that contains objectives are needed in each clinical unit. As one of study participants mentioned, all nurses who are working at the unit should be involved in making an orientation program for the unit. If everyone provides input for the program, they will be more interested in the education of NGNs in the unit. This should create welcoming atmosphere for NGNs.

Furthermore, as Duchscher [34] indicated, it is important to include information about NGNs’ role transition in the orientation program. NGNs did not have a high skill level or confidence; therefore, an extended orientation and support program in each clinical unit are essential to facilitate transition into practice. Information on how NGNs experience role transition is important not only for NGNs but also for all nurses in the unit so that adequate support can be given to NGNs.

This study has several limitations. The study participants were confined to nurse managers whose units were evaluated by the directors of nursing as units where the nurses were working together cohesively. Therefore, the possibility exists that the findings of this study were influenced by this sampling method. The authors concluded that data analysis had reached saturation because no new categories emerged; however, if more interviews had been conducted, specific practices may have been discovered rather than new categories. Regarding a NGN’s integration into a clinical unit, their preceptors and other staff nurses also have important roles to play. Research that incorporates these nurses is needed. Furthermore, this study examined strategies adopted by nurse managers; therefore, the study has not been able to verify if these strategies work for NGNs. Useful strategies from a NGN viewpoint should be identified in the future.

The nurse managers adopted 6 strategies and 3 of them were particularly important for facilitating the integration of NGNs into clinical units: facilitating self-learning, promoting awareness of being a nurse in the clinical unit, and strengthening the sense of comradeship in clinical units. The nurse managers tried to facilitate NGNs’ self-learning by providing opportunities for experience and learning. NGNs’ acquisition of knowledge and skills specific to their clinical unit are imperative for NGNs to be a member of the unit. They also tried to raise the NGN’s awareness of being a nurse in the clinical unit by giving them meaningful roles within the unit.

The central strategy was the strengthening the sense of comradeship of all nurses in their clinical units. This strategy should create a supportive environment for NGNs to integrate into their respective clinical units. The nurse managers implemented this strategy by creating the sense of belonging among both staff nurses and NGNs. To facilitate NGNs’ integration into their clinical units, nurse managers need to adopt strategies that are not confined to NGNs but include all nurses in their clinical units.

All senior nurses who worked with NGNs could apply these strategies to facilitate NGNs’ integration into their clinical units. For NGNs, knowing these strategies would help them to understand what they should do to become a full member of their unit.

The authors confirm that they have no conflict of interest in regard to this manuscript.

This study was approved by the ethical committee of Kobe City College of Nursing, Kobe, Japan. The ethical approval number: 2010-1-10.