QUALITATIVE ANNOTATED BIBLIOGRAPHY

For this assignment you will continue to review current research from South’s Online Library and provide a critical evaluation on that research through an annotated bibliography. An annotated bibliography is a brief summary and analysis of the journal article reviewed. For more information on annotated bibliographies please visit Purdue’s OWL: Purdue Online Writing Lab

A total of two annotated bibliographies are to be submitted (not to exceed one page each). The articles must come from nursing scholarly literature and may not be older than 5 years since publication. Please note that the articles must be research based and reflect a qualitative methodology (review our reading assignments). Web pages, magazines, textbooks, and other books are not acceptable.

Each annotation must address the following critical elements:

  • Explanation of the main purpose and scope of the cited work
  • Brief description of the research conducted
  • Value and significance of the work (e.g., study’s findings, scope of the research project) as a contribution to the subject under consideration
  • Possible shortcomings or bias in the work
  • Conclusions or observations reached by the author
  • Summary as to why this research lends evidence to support the potential problem identified specific to your role specialization ( Family Nurse Practitioner )

Contents lists available at ScienceDirect

Nurse Education in Practice

journal homepage: www.elsevier.com/locate/nepr

Doctorate Studies

Nurse practitioners’ experiences with role transition: Supporting the learning curve through preceptorship

Viktoriya Pleshkana,∗, Leslie Husseyb

a Loewenberg College of Nursing, University of Memphis, 4055 North Park Loop, Community Health Building, Memphis, TN, 38152, USA b School of Nursing, College of Health Professions, Walden University, 100 Washington Ave S. Suite 900, Minneapolis, MN, 55401, USA

1. Introduction

Registered nurse (RN) to nurse practitioner (NP) role transition is characterized by significant changes in nurses’ role, including increased levels of autonomy and new responsibilities of being a prescriber. The problem begins with the gap between NPs’ education and the level of skills required at the start of NP practice. To close the gap between education and practice, preceptorships have been used to support NPs’ clinical learning, both before and after graduation. However, pre- ceptorships used prior to graduation have not had major changes since the 1960s and preceptorships used after NPs graduate are scarce (AACN, 2015; Giddens et al., 2014; LeFlore and Thomas, 2016). Pre- ceptorships are essential for NPs’ clinical skill acquisition.

1.1. Background

NPs are RNs with advanced nursing education and clinical training who are licensed to diagnose and prescribe in the United States (Coombs, 2015). In recent years, the demand for NPs grew due to the shortage of primary care (PC) services (Giddens et al., 2014). The number of practicing NPs has increased by more than 100,000 since 2009 with the current total number of practicing NPs exceeding 234,000 (American Association of Nurse Practitioners [AANP], 2017a). To accommodate this increased need, the number of NP programs also proliferated to approximately 350 (AANP, 2017b). Because NPs obtain their skills through experiential learning, clinical education is the foundation of NP programs. However, the clinical training model has not had major changes in 45 years (AACN, 2015; Giddens et al., 2014; LeFlore and Thomas, 2016).

The RN to NP role transition has been identified as difficult and stressful (Brown and Olshansky, 1997; Flinter and Hart, 2016; Steiner et al., 2008). Though many other medical professions offer residencies to their new graduates, most NPs start practicing independently right after graduation (Hevesy et al., 2016). The ill-supported clinical edu- cation during school is followed by the lack of transition support after graduation (AACN, 2015; Brown and Olshansky, 1997; Donley et al., 2014; Flinter and Hart, 2016; Logan et al., 2015; Roberts et al., 2017;

Steiner et al., 2008; Webb et al., 2015). Employers expect newly graduated NPs to care for a wide range of complex patients. Novice NPs expressed concerns about the lack of training to perform procedures, such as suturing, fracture care, X-ray readings, etc. (Jones et al., 2015). Lack of clinical skills may have an impact on NPs’ transition to practice.

Preceptorship is fundamental to NPs’ experiential learning, both before and after graduation and vital for NPs’ successful transition to practice (Brown and Olshansky, 1997; Jones et al., 2015; Leggat et al., 2015; Wiseman, 2013); however, the literature on preceptorship and transition is scarce (Jarrell, 2016; Poronsky, 2012). Before graduation, NP students struggle with their preparedness for clinical experiences and with the availability of their preceptors and clinical sites. Many preceptors have expressed concern about students’ preparation level and questioned their preparation for practice (Roberts et al., 2017). The challenges of obtaining clinical sites and preceptors have been well documented (Drayton-Brooks et al., 2017). Further, preceptors are struggling to accommodate NP students’ learning needs without having their workload adjusted (Giddens et al., 2014; Keough et al., 2015; Poronsky, 2012). Though preceptorship is at the core of NP clinical education, it is in great need of restructuring and support.

Although many other medical professionals are being supported through well-structured clinical education and residency programs, formal NP preceptorship is uncommon after graduation (Wilkes and Feldman, 2017). With the lack of formal preceptorship to support no- vice NPs’ role transition after graduation, the major source of pre- ceptorship for NPs comes through a formal collaborative relationship with their assigned physicians (Jones et al., 2015). However, the MDs’ abilities to train may be limited. Medical and nursing paradigms differ significantly and yet, MDs are expected to guide NPs in their role transition. Physicians’ knowledge of NPs’ role and scope of practice is important for these professionals’ effective collaboration. However, MDs have little familiarity with NPs’ role, education, and training (Schadewaldt et al., 2013; Van der Biezen et al., 2017), which is the most common barrier to a successful NP and MD collaboration (Schadewaldt et al., 2013). Lack of formal preceptorships after the graduation contributes to NPs’ difficult transition to practice.

It is important to explore the current state of preceptorship support.

https://doi.org/10.1016/j.nepr.2019.102655 Received 17 October 2018; Received in revised form 27 October 2019; Accepted 6 November 2019

∗ Corresponding author. E-mail addresses: [email protected] (V. Pleshkan), [email protected] (L. Hussey).

Nurse Education in Practice 42 (2020) 102655

1471-5953/ © 2019 Elsevier Ltd. All rights reserved.

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Several studies were conducted about NPs’ role transition after gra- duation (Brown and Olshansky, 1997; Chappell, 2014; Flinter and Hart, 2016). Scholars confirmed that NPs’ role transition and preceptorship need support. However, how this transition process is currently sup- ported through preceptorship remains largely unknown. The problem is that NPs’ role transition is difficult and poorly supported through an outdated preceptorship model. Learning about the current state of preceptorship model may add insight into how it can be improved.

2. Theoretical foundation

The theoretical lens of this study consisted of the combination of two theories, Schlossberg’s transition theory, and Collins, Brown, and Holum’s Cognitive Apprenticeship Model (CAM). The concept of tran- sition was guided by transition theory, and the concept of preceptorship was guided by CAM.

3. Aim

The purpose of this study was to explore the NPs’ experiences with their role transition while in a preceptorship. Understanding how NPs transition to practice and how a preceptorship supports their transition may inform educators and employers on how to strengthen the transi- tion.

4. Method

4.1. Study design and approach

The nature of this study was qualitative. The approach to this qualitative inquiry was Van Manen’s (1990) hermeneutic phenomen- ology. When used together, the descriptive and interpretive approaches allow a deeper understanding of the participants’ experiences (Matua & Van Der Wal, 2015). Using phenomenology allowed for a description of participants’ experiences, while applying hermeneutics allowed ex- tracting the essence of participants’ lived experiences in a specific context (Van Manen, 1990). Hermeneutic phenomenology design as- sisted with obtaining and explaining descriptive data in a study specific context.

4.2. Sample

After receiving an Institutional Review Board Approval from the Walden University (Approval Number 01-16-18-0522648), a con- venience sample of 16 currently practicing NPs who had been employed as a NP for at least three months but no longer than five years and who had a current collaborative agreement with an MD, was recruited through the Greater Memphis Area Advanced Practice Nurses Association, social media sites, and snowballing.

4.3. Data collection

Sixteen participants were interviewed by the author using a seven question interview protocol. One face-to-face, three Skype, and 12 phone semi-structured interviews were conducted. The interview questions were based on an extensive review of literature and the transition and CAM theories described above. Each interview ranged from 37 to 95 min. Audio recordings were manually transcribed and transferred into the MAXQDA program.

4.4. Data analysis

All data were transcribed manually by the authors using the MAXQDA qualitative data analysis software. Data analysis was con- sistent with the chosen hermeneutic phenomenological design guided by Van Manen’s approach. Sixteen transcribed interviews were coded

using Van Manen’s analysis strategies. During the initial stages of open coding, transcripts were read several times. Field notes created during the transcription process were analyzed. Over 200 codes were derived and each was assigned a memo (code’s short description). Next, data were analyzed according to the two participants’ role transition stages (pre and post-graduation), clinical settings where their experience took place, participants’ relationships with their preceptors, and their reac- tions to their role transition experiences. Seven major themes were identified. MAXQDA analysis program assisted in proper data display and its easy retrieval.

4.5. Trustworthiness

To ensure data trustworthiness, data credibility, transferability, dependability, and confirmability were established. Clear, detailed de- scriptions, prolonged engagement with participants and data, rich data, and triangulation were ensured. Prolong engagement with participants was achieved by conducting interviews. Longer interviews allowed es- tablishing of trust between researcher and participant leading to a more comfortable discussion of the phenomenon by the participant. Triangulation in data collection was established through multiple data collection methods. Namely, to collect data, field notes and partici- pants’ descriptions were used.

4.6. Ethical considerations

All study participants were provided with the written information regarding the study purpose and research process. All participants re- ceived information about the study prior to and during the interviews. All participants were informed of the voluntary nature of their parti- cipation and ability to cancel at any time. All participants consented via e-mail and received an Amazon certificate of $10 dollars after the in- terview.

5. Results

In exploring participants’ experiences with their transition to prac- tice and preceptorship before and after the graduation, the following seven themes emerged from the data, (a) transition preparation and learning; (b) preceptorship during role transition and learning; (c) learning to care for complex patients; (d) learning in clinical environ- ment; (e) transitioning to a greater autonomy and new responsibilities; (f) embracing the role and identity confusion, and (g) transition reac- tions (Table 1).

5.1. Theme I: Transition preparation and learning

In this theme, participants’ preparation for clinical experiences pre and post-graduation was explored during their role transition. Prior to graduation except for the occasional “meet and greet” clinical or- ientation, there was no other preparatory work before the participants’ start of their clinical rotations. Participants were not aware of their preceptors’ expectations or work style until the start of their clinical rotations, “P5: I don’t feel like I understood what was going to be

Table 1 Themes.

Theme Number Theme Name

Theme I Transition preparation and learning Theme II Preceptorship during role transition and learning Theme III Learning to care for complex patients Theme IV Learning in clinical environment Theme V Transitioning to a greater autonomy and new responsibilities Theme VI Embracing the role and identity confusion Theme VII Transition reactions

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expected of me in clinical.” Immediately after graduation, many par- ticipants reported feeling unprepared to practice independently, “P2: You kind of just get thrown and figure it out.” Many reported lack of orientation for their clinical experiences while in school. Similarly, post-graduation, many reported lack of adequate onboarding process.

5.2. Theme II: Preceptorship during role transition and learning

The second theme contained the data related to the instructional strategies used to precept NPs pre and post-graduation. Before gra- duation, the most effective instructional strategy reported was “see one, do one,” in which the preceptor demonstrated the skill and then ob- served the student perform the skill, after which, the student performed more independently. However, such hands-on experiences were rare: “P16: the only procedure I really got to do in clinicals … doing a pelvic exam.” Preceptors’ teaching styles were reported to be inconsistent among various preceptors and clinical settings. Preceptors’ workload and lack of day to day feedback frequently prevented them from pro- viding participants with adequate instruction, “P12: … 40 patients a day, so I don’t know if they had time to sit down and explain a lot of stuff to me.” Case discussions and debriefings were frequently omitted from students’ learning experiences due to the time constrains.

After graduation, participants learned their NP role through self- teaching and asking questions, “P1: most of the things that I have learned and that I do it is because I looked it up and I researched it myself.” Though all participants had collaborative agreements with their MDs expecting them to mentor, many reported minimal to no help from their collaborators: “P14: … post-graduation I had collaborators on paper and … I did not have anyone to really break down my day to … I wish I may be had some support…” Being left alone to learn and master their new skills generated feelings of stress and fear.

Both before and after graduation, participants reported their pre- ceptors’ lack of time to teach them, which affected participants’ ability to learn their clinical skills. Overall, dependence on their preceptors for clinical decision making prior to the graduation was changed to a lack of formal preceptorship after graduation. Because most did not have access to a formal preceptor and many participants’ collaborators were unavailable to mentor, self-teaching was employed extensively by all participants post-graduation.

5.3. Theme III: Learning to care for complex patients

Theme III included participants’ experiences with learning how to care for complex clients before and after graduation. Participants’ ex- periences with learning complex patient care while in the program were random, “P16: it was like completely random because you were just lucky to get what you could get.” When advancing to clinical practice after graduation, participants reported “rude awakening” as they did not feel prepared to care for complex patients independently right after graduation. Participants reported the lack of support from their em- ployers’ administration as they did not yet feel equipped to care for complex clients and were in need of such support, “P16: So complex patients is what I really struggled on when I first became an NP … trying to like cram all that in, assess the patient, talk to them, figure out everything to and change in like 15 min, it was very, very over- whelming at first.” Participants particularly struggled with poly- pharmacy, comorbidities, noncompliant clients, complex diagnoses, underserved, and less known patients. Without having adequate structured support, participants struggled with managing their time as well as took some of their work home. Learning to care for complex clients was preceptor and cite dependent while in NP program, which translated into an overwhelmingly steep transition post-graduation.

5.4. Theme IV: Learning and clinical environment

Participants’ experiences with clinical sites and preceptors prior to

graduation and collaboration support post-graduation were explored. Before graduation, most NPs reported the greatest challenge was finding and securing clinical sites and preceptors, which often led to mismatch between the preceptors, sites, and student’s learning needs, “P8: …. it was so hard you pretty much take anyone you could get and there was no way of telling if they were going be good teacher.” A mismatch between the clinical sites and students’ learning needs led to limited training opportunities available to NP students.

While locating the sites was one of the most stressful components of many participants’ experiences, frequent preceptor change with a lim- ited number of clinical hours spent with each preceptor led to shorter clinical rotations. In this study, short clinical rotations along with mismatch and lack of selectiveness when securing sites and preceptors led to a decrease in students’ autonomy during their clinical rotations. After graduation, participants’ relationship with providers they were learning from was reported as important to their successful transition to practice. Those participants who were learning alone reported more challenging transition experiences. Lack of selectiveness in sites and preceptors prior the graduation translated into the participants’ need for their employers’ support, which was often not available.

5.5. Theme V: Transitioning to a greater autonomy and new responsibilities

Participants’ experiences with advancing to a greater level of au- tonomy and new role responsibilities were explored. Increased de- pendency on preceptors along with decreased hands-on clinical ex- periences led to reduced autonomy during school clinical experiences, “P14: …. I never had a situation that I had to do it on my own in any of my rotations.” When in NP program, participants reported little in- dependent decision making, prescribing, or practicing differential di- agnoses.

After graduation, a sudden increase in autonomy, accompanied by the lack of support, led to participants feeling unprepared, “P14: … very challenging lots of frustration, lots of thinking I chose the wrong profession …. ” Participants reported having particular difficulties with autonomously prescribing multiple medications, coding, diagnosing, and laboratory testing interpretation. Many reported day dreaming of returning to their “safer” RN role; however, too much was already in- vested in NP degree. While participants were overwhelmed with their new responsibilities, they also appreciated the new autonomy level and began to embrace it when becoming more comfortable with new re- sponsibilities.

5.6. Theme VI: Embracing the role and identity confusion

Participants’ experiences with identifying with their new role of an advanced practice nurse were explored. While some participants re- ported that practicing in an RN role was helpful in learning how to be an NP, others reported it being confusing, “P16: I would go from I am the one making the decisions and ing stuff during the week on patients too, now on the weekend I can’t do any of that, I am just like following s, so it was really weird to live in both of those worlds at the same time.” After graduation, when in an NP role, participants re- ported that it was hard not to perform in both roles, RN and NP since their new role functions were not clearly defined. Such unclear role boundaries led to confusion about the scope of an NP role.

5.7. Theme VII: Transition reactions

Participants’ reactions to their experience with the transition before and after graduation were explored. While feeling stressed out about finding preceptors and sites when in the program was commonly re- ported, participants did not express concerns about their new role re- sponsibilities, “P11: I was not stressed out or anxious at all when I was an NP student, because the responsibility was not on me and now the responsibility is on me.” After graduation, most of reported emotional

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reactions to NP transition experience were negative. Participants felt fearful of making a mistake that could negatively affect their patients’ health, “P14: can you imagine killing somebody unintentionally, acci- dently because you did not get the right support; that left me very stressed out, very unfulfilled in my role as an NP, I thought I was going to be coming in making a world of difference … I feel alone…” It was important to explore participants’ feelings as part of their role transition experience because human feelings and reactions constitute an im- portant part of any experience.

6. Discussion

Findings suggested that NPs’ difficult transition to practice was re- lated to the lack of their preceptorship support in NP school and in NP work settings. The data showed ill-supported preceptorships when in NP programs. Lack of preceptorships after graduation was accompanied by employers expecting novice NPs to function at an expert level, fre- quently with minimal guidance. Understanding how NPs transition to practice and how their role transition is supported through preceptor- ships can be used to inform NP educators and organizations that hire NPs of the changes needed to strengthen NPs’ role transition.

The study findings provided insights into how NPs’ role transition is supported through preceptorship during the two transition stages, pre and post-graduation. An abrupt increase in autonomy from pre-gra- duation to post-graduation transition stage accompanied by the lack of support was this study’s central finding. The awareness of new re- sponsibilities did not take place until the post-graduation transition stage, which was the result of overreliance on preceptors for clinical decision making while in the program. Similarly, Cusson, and Strange (2008) found that the time of performing independently coincides with the time of becoming aware of new responsibilities. The abrupt increase in autonomy coincided with identity confusion.

Struggling to identify with their new role as an advanced nurse, trying to merge the roles of nursing and medicine, participants reported their role boundaries were blurred. This finding was consistent with Jangland et al. (2016) who reported that being positioned in between the two roles caused identity confusion. Similarly with Brown and Olshansky (1997), feelings of being an imposter were reported in this study. NPs enjoyed their new autonomy after settling into their role, confirming that increased autonomy level facilitates NP role transition (Faraz, 2017, 2019; Horner, 2017). However, the abrupt change from overreliance on preceptors while in the program to a poorly supported role transition post-graduation caused NPs to feel fearful and alone, which was consistent with previous studies on NP role transition (Barnes, 2015b; Brown and Oshlansky, 1997; Hart and Macnee, 2007; Heitz et al., 2004). This variation between the pre and post-graduation autonomy level combined with blurred role boundaries may be a culprit of NPs’ difficult role transition.

When exploring NPs’ experiences with preparation for their clinical rotations, consistent with Babcock et al. (2014), Flott and Linden (2016), and Roberts et al. (2017), this study’s findings confirmed that having an EMR access, becoming familiar with clinical site’s workflow, as well as preceptors’ and students’ expectations were critical. Frequent preceptor changes and shorter clinical rotations led to preceptors’ lack of comfort with their NP students, which caused an increase in ob- servation-only clinical hours. Similarly to Hallas et al. (2012) results, participants’ clinical hours did not translate into attaining all necessary competencies prior the graduation. Though hands on clinical experi- ences were always desired by participants, they experienced many observation-only clinical hours while adjusting to their new preceptors and learning the workflow of their clinical sites. To assist NP students with preparation for their clinical rotations, it may be beneficial to assign some observation-only clinical hours prior starting clinical ro- tations. It may also be of benefit to minimize preceptor and site changes to increase students’ clinical hours with each preceptor to allow learning of more complex skills. Lack of NP students’ preparation for

their clinical rotations was followed by rushed and variable pre- ceptorship process.

When exploring preceptorship during NPs’ role learning, incon- sistent preceptors’ teaching styles, lack of feedback, and preceptors’ heavy workload were identified. Bazzell and Dains (2017) reported the lack of guidelines to train preceptors and Marfell et al. (2017) under- lined the importance of feedback in mentoring. Preceptors’ heavy workload assignments combined with the lack of training on how to precept impacted NP students’ learning of their clinical skills. While preceptorship processes varied significantly, securing preceptors was also a challenge.

Challenges with finding and securing clinical sites were identified and consistent with AACN, 2015, Drayton-Brooks et al. (2017), and Erikson et al. (2014) findings. Poorly supported preceptorship com- bined with difficulties in finding clinical sites and preceptors impeded NPs’ clinical skills acquisition when in the program. Consistent with Hart and Bowen’ (2016) and Wilkes and Feldman (2017), this study showed that formal preceptorship was uncommon post-graduation leaving NPs to learn from others informally. Though, mentorship is essential to one’s successful transition to practice (Barnes, 2015a; Faraz, 2016; Farrell et al., 2015; Hill and Sawatzky, 2011; Zapatka et al., 2014), patient care takes priority decreasing time available for men- toring NPs (Bazzell and Dains, 2017; Forsberg et al., 2015; Giddens et al., 2014; Keough et al., 2015; Poronsky, 2012; Roberts et al., 2017). Training preceptors and decreasing their’ workload pre graduation, as well as creating formal preceptorships post-graduation, may provide a stronger foundation for NPs’ role transition.

When exploring how NPs learned to care for complex clients, lack of predictability of learning opportunities led to NPs graduating without having sufficient knowledge in managing patients on multiple medi- cations or those with multiple comorbidities causing them to doubt their skills. These findings were consistent with Jones et al. (2015) who found that NPs lacked preparation to care for complex elder patients. To address the gap in knowledge related to treating complex patients, it becomes necessary to include competencies specific to the complexities of patient care. Consistent with Hart and Bowen (2016), Jones et al. (2015), and Logan et al. (2015), many participants reported feeling unprepared to practice post-graduation. Similarly with the results of Fitzpatrick and Gripshover (2016), O’brien et al. (2009), and Sargent and Olmedo (2013), participants struggled to fulfill unrealistic em- ployers’ expectations in an absence of formal onboarding processes. After the graduation, post-graduation residency programs should pro- vide NPs with much needed mentorship component to close the gap between graduation at an entry level and employers’ requirements for expert NPs.

7. Limitations

This study was limited to NPs who were employed in an NP role in the United States for at least three months but no longer than five years. Additionally, data accuracy depended on participants’ recall. Because all participants had already graduated and started working in their new role, it was more difficult for them to recall their pre-graduation ex- periences. Recruitment was limited to those participants who vo- lunteered their participation. It is possible that NPs’ experiences with transition could steer them in their decision of whether to participate in this study. Due to the qualitative nature of this study, transferring the results outside the study setting and the population is not possible unless additional studies are conducted.

8. Conclusion

Understanding how NPs’ transition to practice process is supported through preceptorship is important in strengthening NPs’ clinical skills acquisition during the two transition stages, before and after gradua- tion. This study showed that while in school, NPs’ experiences with

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clinical skill acquisition were variable and ill-supported. Overreliance on clinical preceptors while in a program translated into an un- supported and stressful transition to practice post-graduation. Participants described that their role change after graduation started with excitement as they welcomed and embraced the new role, but quickly changed to the realization of new responsibilities of a new role combined with feeling unprepared to care for complex patients and the lack of transition support. Educators and employers have an opportu- nity to strengthen NPs’ transition to practice through restructuring the weakest but one of the most important elements of NP role transition, preceptorship. Training and adjusting preceptors’ schedules to allow learning to take place when in the program should provide NP students with the support necessary for them to increase autonomy of their clinical decision making. After the graduation, well-structured on- boarding programs and post-graduation residency programs should be employed to allow for a more gradual increase in autonomy to establish NPs’ safe transition to practice. The successful role transition process may lead to more NPs choose to stay in a role; thus, improving the quality and availability of health care services.

Funding sources

None.

Ethical approval details

IRB approval was obtained from the Walden University (Approval Number 01-16-18-0522648). All participants consented via e-mail and received an Amazon certificate of $10 dollars after the interview.

Declaration of competing interest

None.

Acknowledgements

Donna Bailey, PhD.

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  • Nurse practitioners’ experiences with role transition: Supporting the learning curve through preceptorship
    • Introduction
      • Background
    • Theoretical foundation
    • Aim
    • Method
      • Study design and approach
      • Sample
      • Data collection
      • Data analysis
      • Trustworthiness
      • Ethical considerations
    • Results
      • Theme I: Transition preparation and learning
      • Theme II: Preceptorship during role transition and learning
      • Theme III: Learning to care for complex patients
      • Theme IV: Learning and clinical environment
      • Theme V: Transitioning to a greater autonomy and new responsibilities
      • Theme VI: Embracing the role and identity confusion
      • Theme VII: Transition reactions
    • Discussion
    • Limitations
    • Conclusion
    • Funding sources
    • Ethical approval details
    • mk:H1_25
    • Acknowledgements
    • References
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