Exploring the Factors that Affect the Transition from Students to Health Professionals: An Integrative Review


 Background: The nature of a new health professional’s transition from student to health professional is a significant determinant of the ease or difficulty of the journey to professional competence. The integrative review will explore the extent of literature on the factors that impact the transition of new health professionals into practice, identify possible gaps and synthesise findings which will inform further research. The aim was to identify research conducted in the last two decades on the barriers, facilitators and coping strategies employed by new health professionals during their transition into practice.Methods: Whittemore and Knafl’s methodological framework for conducting integrative reviews was used to guide this study. Sources between 1999 and 2019 were gathered using EBSCOhost (including CINAHL, Medline, Academic Search Premier, Health Science: Nursing and Academic Edition), PubMed, Scopus, Cochrane and Web of Science, as well as hand searching and follow-up of bibliographies followed. The Covidence platform was used to manage the project. All studies were screened against a predetermined selection criteria. Relevant data was extracted from included sources and analysed using thematic analysis approach.Results: Of the 562 studies identified, relevant data was extracted from 24 studies that met the inclusion criteria, and analysed to form this review. Thematic analysis approach was used to categorise the findings into theme areas. Four overarching themes emerged namely: systems and structures, personal capacities, professional competence and mediating processes. Each theme revealed the barriers, facilitators and coping strategies of transition into practice among new health graduates.Conclusion: The transition into practice for new health practitioners has been described as complex and a period of great stress. Increasing clinical and practical experiences during education are required to support new health professionals in the process of closing the gap between learning and practice. Continued professional development activities should be readily available and attendance of these encouraged.

The nature of a new health professional's transition from student to health professional has been shown to be a signi cant determinant of the ease or di culty of his/her journey to professional competence (2,12). Several strategies were found to alleviate the challenges that characterise the transition from student to health professional. Consistent emphasis is placed on supervision to help new health professionals relate the knowledge acquired in the classroom to practice (4,(12)(13)(14)(15). Effective supervision equips new health professionals with skills needed to function in their respective areas of practice (13). Moores and Fitzgerald (12) established that meaningful interactions with other new health professionals in the form of study groups, peer support meetings and social interaction sessions contribute signi cantly to successful transitions to practice (14). Other support strategies emphasised in the literature include adequate orientation for new health professionals (11), support from more experienced senior colleagues (15), preceptorship programmes (16) and other health professionals (17). New health professionals have also been advised to utilise continuing education opportunities. Evidence suggests that continued professional development avenues positively impact on new health professionals' selfcon dence and professional identity (7).
This integrative review aimed to identify research conducted in the last two decades (1999-2019) on the barriers and facilitators associated with new health professionals' transition into practice and the coping strategies employed to ensure successful transition into practice

Methods
The integrative review commenced with publication of the protocol so as to obtain peer input (18).
Whittemore and Kna 's (19) methodological framework for conducting integrative reviews guided this study (See Figure 1); the process will now be discussed in detail.

Problem Identi cation (Preparing guiding question)
The overarching question that guided this review was 'what factors affect the transition of new health professionals from students to health professionals?' To capture the scope and the diversity of available literature, three speci c research questions were developed to answer the question.

Data evaluation
Titles and abstracts of all retrieved sources were uploaded onto the Covidence Platform, which was used to manage the project. The Covidence platform automatically removed duplicates before the review process began. Quality assessment was undertaken to ensure the clarity of study aim, the participants and the relevance of the of the study to answer the research question. All studies were assessed for eligibility by three independent reviewers according to the following criteria: Primary sources of systematic reviews that meet the inclusion criteria.
Systematic or literature reviews

Published in English
Published after 1999 Following the title and abstract screening, full texts of the included studies were upload for full text screening against the same predetermined selection criteria. Con icts were resolved through consultation among the three reviewers until consensus was reached. Once consensus was reached on the eligibility of sources, data was extracted from full text publications using a data charting form adapted from Uys et al (20). For each of the included studies, the researcher extracted the study characteristics (author names, publishing journal, year study was published, country of study and the population of the study), study aims, objectives and/or research questions, the study design and the ndings (with particular emphasis on the barriers, the facilitators and coping strategies of transition into practice).

Data Analysis and Presentation
Once the data extraction process was completed, ndings were analysed and categorised into themes areas using a thematic analysis approach (21); this involved summary and categorization of data into codes, sub-themes and main themes. The analysis focused on extracting data that met the objectives of this study. The rst author did the analysis, which was then reviewed and re ned with the assistance of the second and third authors. Once the data evaluation and analysis processes were completed, the study ndings were presented in the form of descriptions and narrations.

Study Selection
The primary search strategy identi ed 562 studies from which 185 duplicates were removed. The title and abstract of 377 sources were screened and 284 were excluded. The full texts of the included sources were uploaded onto the Covidence platform for full text screening against the same predetermined inclusion and exclusion criteria. Overall, 92 studies were assessed for full-text eligibility. A nal total of 24 studies met the inclusion criteria and relevant data was extracted and analysed to form this review (See Figure 2: PRISMA ow chart of study selection)

Study Characteristics
Most sources originated in Australia (n = 8; 33.3%), followed by Canada (n = 5; 20.8%), the USA (n = 3; 12.5%), the UK (n = 2; 8.3%) and Norway, Turkey, Oman, Jordan, Philippines and Ireland (n=1 for each country; 4.2%). Twenty sources used qualitative methodologies, 3 used quantitative methodologies and one study used mixed methods. Thirteen sources pertained the profession of nursing (54.2%), seven were on occupational therapy (29.2%), two about medicine/doctors medical (8.3%) and one each on physiotherapy and midwifery (4.2%). Table 2 presents a summary of the sources that were included in the review including characteristics such as rst author, year of publication, country of origin, study aims, sample size, profession of participants, the methodology used and the publishing journal. negatively, were identi ed. Their experiences pertained and multifaceted experiences of new health professionals with self, clients, other health professionals, workplace protocols and the healthcare delivery system as a whole. Once data were charted, ndings were summarised and categorised into codes, sub-themes and main themes. Four overarching themes were developed: 'systems and structures', 'personal capacities', 'professional competence' and 'mediating processes' with a number of sub-themes (see Figure 3:Theme and sub-themes derived from data analysis ).

Discussion
The challenges, facilitators and the coping strategies shown to affect the transition into practice for new graduates from various health professions will now be discussed in more detail.

Theme 1: Systems and structures
The theme 'systems and structures' re ects the barriers new health practitioners had to overcome and the challenges they faced during transition to practice; it comprises ve sub-themes, namely workplace constraints, workloads, support and guidance, expectations, and respect and recognition.
Workplace constraints: Among the challenges encountered by new health professionals were those relating to the complexity of systems in the workplace. New health professionals reported having a naive understanding of the hierarchy of the system, administrative processes, workplace politics and organisational dynamics; this impacted on their transition into practice (4,6,14,16,33). One study reported that, not knowing the "what, how, why, where and when" of workplace routines posed various challenges for new health professionals (4). Variations in operations and administration also served as a source of frustration for new health professionals as they moved between workplaces (35). New health professionals were expected to automatically adapt to 'the-way-things-are-done' and the 'it-is-alwaysdone-this-way' operational culture in the wards (15). Most of these procedures were experienced as contrary to what new health professionals had been taught, thus causing confusion (16).
Workloads: Complex and overwhelming work-related responsibilities were experienced among new health professionals (3,4,16,29,31). One study reported that new health professionals were expected to handle complex cases and procedures which they considered unreasonably beyond their capabilities as novice professionals (3). Research also reported heavy patient loads among new health professionals which require them to either work overtime or work under pressure in order to meet all responsibilities (31). New health professionals generally felt overworked at the end of the day (27).
Respect and Recognition: A lack of respect and recognition for new health professionals during transition into practice was reported. Phillips et al (11) suggested that new health professionals were not afforded the respect they deserved, especially those that were younger. They emphasized that, lack of respect undermined new health professionals' self-con dence, which translates into a lack of self-worth (11).
Unprofessional behaviour from other health professionals and senior colleagues, included experiences of being treated as subordinates (16) as well as bullying and insults (5), negatively impacted on the adjustment of new health professionals. Reynold et al (29) and Tryssenaar (32) reported that new health professionals did not feel valued in their practice. In fact, one study reported that new health professionals considered quitting their jobs after the rst year due to lack of recognition and appreciation and an overall experience of dissatisfaction at work (28). Support and Guidance: The importance of having a well-structured system of support and guidance for new health professionals during their transition was emphasized. New health professionals who have su cient orientation programmes reported doing well during their transition into practice (11,13,16,31,32). Conversely, new health professionals who did not get su cient orientation encountered di culties with the transition (4,16,21,26). In addition to orientation programmes, strategies found to support new health professionals' transition into practice included residency programmes (23), preceptorship programmes (13,28,31) and mentoring programmes (5,16,22). New health professionals needed support from experienced senior colleagues (4,5,11,16,23,30,31) as well as peers (4). New health professionals reported feeling motivated to perform better when they received feedback on their performance from other health professionals (33) and clients (31). Particular emphasis was also placed on supervision as an effective strategy to help new health professionals overcome the stressors of the transition (6,7,11,13).
Expectations: New health professionals reported feeling overwhelmed by unrealistically high expectations placed on them (3,13,25,26,29). Labrague et al (3) reported that new health professionals felt pressured and stressed when unachievable expectations were placed on them. Nurses in Clare & Loon's (5) study expressed gratitude to their superiors for having realistic expectations of their skills. They further emphasized that realistic expectations gave them the opportunity to grow their con dence (5). Furthermore, new health professionals reported that they were ignorant of what was expected of them (7,26). In Zinsmeiter's (34) study, new health professionals reported that when all health professionals (new and existing) have clear expectations of their role, the transition becomes comfortable.

Theme 2: Personal Capacities
In the theme "personal capacities" the personal characteristics of new health professionals that in uence their transition from student to health professional were captured; it comprised three sub-themes, namely self-perceived competence, self-con dence, and intrinsic motivation to perform.
Self-perceived competence: One factor that affected new health professionals' transition into practice was their perception of their own competence. New health professionals' perception that they do not know enough made them question their competence and readiness for practice (4,6,7,(18)(19)(20)(21)(22)26,27,(31)(32)(33). Several situations were reported where new health professionals were caught in a dilemma related to diagnosis, assessment or treatment procedures (5,7,23). Nurses in Clare's (5) study described the overwhelming feeling of inadequacy as the worst aspect of their transition. Feeling inadequate resulted in new health professionals feeling vulnerable and fearful of taking on responsibilities because of their fear of making mistakes (23,29).
Self-con dence: Con dence was emphasized as a personal quality that contributes signi cantly to the success of transition into practice. However, self-con dence seemed to be determined primarily by new health professionals' perception of how competent they were and how prepared they were for practice (4,10,11,17,21,22,24,32). A quantitative cross-sectional survey by Doherty et al (10) revealed that new occupational therapy graduates' perceived self-con dence had a signi cant positive relationship with their self-perceived competence level in clinical decision making.
Intrinsic Motivation to perform: New health professionals reported several factors motivating them to continue to pursue competence in the face of challenges encountered during transition. The fact that they were playing an integral role of changing the health of patients for the better motivated them to persist. Others found motivation by associating their role to the spiritual bene ts they expected in future (16).
Other new health professionals were motivated by the excitement in acquiring new skills and growing in their professions (3,5).

Theme 3: Professional competences
This theme re ected the relationship between knowledge, skills and attitudes new health professionals acquired through their education, and practising in the eld. Three sub-themes emerged, namely academics-practice disparity, professional knowledge and skills, and practical experiences.
Academics-practice disparity: Research ndings reported a dichotomy between what was learnt in the classroom and the expectations of actual performance in practice (3,4,16,21,29). De Bellis et al (4) emphasized that the knowledge participants in their study acquired from their undergraduate education was not applicable in their practice. The incongruency between education and practice was believed to often lead to a reality shock in the practice environment. (23)The sources reviewed suggested that new health professionals experienced high levels of tension, coupled with anxiety and nervousness upon entering the world of practice (6,7,20,(25)(26)(27)29,32,33). O'shea et al (22) emphasized that the 'reality shock' and anxiety among new health professionals was intense, particularly in the rst ve months of transition into practice. New health professionals often experienced con ict between their expectations of practice and the reality of practice (31). They experienced varying levels of stress beyond their expectations which impacted their transition (3,6,13,20,21,25,26,(30)(31)(32)(33). New health professionals often felt incapable of managing stressful emotional work-related situations such as death and dying (13,20,23).
Professional knowledge and skills: The sources reviewed suggested that it is in practice that new health professionals become aware of de cits in their knowledge and skills. The gap between education and practice can cause a mismatch between new health professionals' expectations of their roles and what is actually practiced on the eld, leading to role confusion (6,13,29). New health professionals demonstrated inadequacy in clinical practice skills such as communication skills (10,22,24), organisational and management skills (16,20,22), clinical decision-making skills (5,22) and skills required for speci c practice areas (6,16,29). Newly quali ed occupational therapists in a study by Toal-Sullivan (31) reported that they felt unprepared in specialised clinical skills, such as splinting, cognitive remediation, wheelchair prescription, hand therapy and home safety equipment.
Practical experience-: Inadequacies in the knowledge and skills of new health professionals was strongly associated with insu cient practical and clinical exposure in their undergraduate training (4)(5)(6)21). Increasing hands-on experience of new health professionals during education can help prevent inadequate knowledge and skills during practice (7). Occupational therapists in their rst year of practice emphasized that prior clinical placement experience helped ameliorate the stress and uncertainties that characterised transition into practice (7). Brennan et al (25) also emphasized that new health professionals should cultivate a 'doing, not observing' attitude during transition into practice.

Theme 4: Mediating processes
This theme captured the strategies employed by new health professionals to change or manage challenges they encountered during transition into practice. Four sub-themes emerged, namely learning as an ongoing process, establishing supportive contacts, asking for help, and effective time management.
Learning as an ongoing process: Research emphasized the importance of new health professionals recognising that professional competence comes through continuous learning and experience (7,17,33).
New health professionals should not expect themselves to know everything when transitioning into practice, rather, they should view their knowledge and skills within the con nes of being a new health professional (17). With this mindset, new health professionals were advised to strive towards professional competence through personal reading (4,22), revisiting lecture notes (4), taking continuing education courses (6), learning from the mistakes they make (24), creating informal learning culture together with peers (35) and observing and learning from experienced senior colleagues (24).
Asking for help: New health professionals resorted to 'asking for help' when they did not know what to do (35) and sought supervision when confronted with new situations (4,6). In situations where there were no mentors and supervisors, new health professionals sought remote mentors and coaches (6). Listening and regularly asking questions were also emphasized as coping strategies to ameliorate the challenges of transition (4,22).
Effective time management: Effective time management strategies were found to help alleviate some challenges of transition (6,7). New occupational therapy graduates reported that managing their time well enabled them to deal with overwhelming work schedules, prevented having to work overtime and allowed time for meaningful personal and social lives (6).

Conclusion
New health professionals encounter numerous challenges during their transition into practice, however, support strategies can ameliorate the di culties experienced and the coping strategies employed by new health professionals can help to make the transition successful.
Orientation programmes are needed. These should include information on systems and procedures, presented in a format that is easily accessible to new generation learners, and detailed and comprehensible enough to deal with challenges that cause unnecessary anxiety. In addition to support from line managers, new health professionals bene t from mentor and peer support. We recommend both formal and informal systems fostering the creation of support networks..
Orientation programmes should encourage new health professionals to request support or supervision from senior colleagues. Conversely, senior colleagues should maintain a good professional relationship with new health professionals and accord them due respect and recognition. This will make it easy for new graduates to approach senior colleagues for professional assistance.    Themes and sub-themes derived from data analysis.