DOI: https://doi.org/10.21203/rs.3.rs-1953037/v1
Background: New nurse graduates encounter a myriad of experiences in their first employment setting as a result of the lack of knowledge, specialized skills, transition shock, and other aspects of the situation. There is a lack of tools to assess the experiences encountered during the transition process in China. The aim of this research was to explore the reliability and validity of Chinese version of the Transition Shock Scale for Newly Graduated Nurses (TSSNGN) among recent Chinese nurse graduates.
Methods: The Korean version of TSSNGN was translated and culturally adapted by Beaton and his colleagues based on the instrumental adaptation process. A methodological research design was adopted for the study. Newly graduated Chinese nurses (N=327) were recruited using convenience sampling method. All of the participants were investigated by the Chinese version of the TSSNGN and a socio-demographic questionnaire. The content, construct, convergent, discriminant, and criterion-related validity and the reliability of the scale were examined.
Results: The TSSNGN Korean version includes 18 items. A modified index was used to improve the model fit and it supported the reliability of the Korean version of the TSSNGN model. Analysis of fit of the revised Chinese model using Nomed χ2 (CIMIN/df) showed: fit indices to 3.09, RMSEA = 0.07, RMR=0.03, GFI= 0.90, IFI =0.92, TLI=0.90, CFI=0.92. Criterion validity compared to the PSS showed significant correlation, and the Cronbach’s alpha was 0.92. Factor loadings of the 18 questions ranged from 0.49 to 0.87.
Conclusions: The simplified Chinese version of the TSSNGN is valid and reliable to assess the transition shock of newly graduated Chinese nurses.
Widespread nursing shortage due to high nurse turnover is a global burning issue [1]. Meanwhile, the demand for nurses is influenced by rapid development and changes in the social economy, advances in medicine, nursing and healthcare systems. Newly graduated nurses play a crucial part in shaping the future of nursing, not only replacing an aging workforce but ensuring the survival of the nursing profession [2]. Newly graduated nurses are defined as nurses who have worked less than a year after graduation by most scholars [3, 4]. This is a challenging time for newly graduated nurses, most of whom initially transitioned to professional practice in a hospital setting. They are faced with a challenging work environment that may impact their career development. Work stress, experiences of lateral violence, feeling caught off-guard, social difficulties, reality shocks and personal changes, and increased educational demands are among the issues faced by newly graduated nurses. Various barriers, including risks and challenges in the clinical environment, place higher demands on newly graduated nurses [5]. They must face significant changes in responsibilities, roles and relationships. Research has shown that newly graduated nurses often have problems of anxiety, tension and low job satisfaction at the initial stage of their career in foreign countries [6, 7]. New Chinese graduates with minimal experience have problems such as mechanical execution of medical orders, lack of ability and technical unproficiency [8]. Moreover, due to their lack of knowledge, skills, etc., they face enormous pressure and even transition shocks when entering clinical work [9].
The theory of Transition Shock was proposed by Duchscher [10] based on four qualitative studies and a comprehensive literature review. The theory outlines how contemporary fresh graduates face the broad range and scope of physical, intellectual, emotional, developmental, and sociocultural changes that are manifest and mitigating factors in the experience of transition when they first take up professional practice roles. This theory was not only applied to the nursing field, but also other employment fields [9]. The research on the transition of new nurses in China is based on this theory [3].
Several studies have shown that one-year turnover rate of new nurses is 35% ~ 60% due to transition shock [11, 12], and new nurses in China also encountered similar problems [13]. The shortage of nurses has become a worldwide concern. In order to alleviate the shortage of nurses due to transition shock, reliable tools are needed to assess the transition shock experienced by newly graduated nurses and help them overcome it successfully. There are two versions of the TSSNGN.
The Chinese version was developed by a Chinese scholar [14], based on Duchscher's theory of Transition Shock, which includes 27 items in four dimensions: physical, psychological, knowledge and skills, sociocultural, and developmental. It had good reliability and validity, and was mostly used in non-qualitative researches to assess the degree of transition shock of newly graduated nurses in China [3].
The Korean version was developed by Kim and colleagues based on a literature review and qualitative research. It consists of 18 items, and includes six dimensions: conflict between theory and practice, excessive workload, loss of social support, shrinking relationship with colleagues, confusion in professional nursing values and incongruity between work and personal life [15].
The current research used the Korean version of the TSSNGN, which was translated into Mandarin. No research has used the Chinese version of this scale so far. In order to understand the application effect of the Korean version of the scale, it was translated into Mandarin and tested for reliability and validity for this study. Thus, it aims to provide a reference for clinical nurse managers in understanding the issues facing newly graduated nurses as they transit into employment.
This study aimed to examine the reliability and validity of the Korean version of the TSSNGN among Chinese nurses.
A cross-sectional study was used and included 327 new nurses who were brecruited using convenience sampling from a tertiary hospital in Hubei Province in central China. Data collection was completed from August to September 2019. This study was ethically approved by the Ethics Committee of Wuhan University School of Medicine. Participant inclusion criteria were as follows: (1) nurses having graduated in June 2019 with a master’s degree or bachelor’s degree in nursing, or from a junior college; (2) entry into employment < 3 months after graduation; (3) having passed the vocational qualification examination for nurses. Exclusion criteria were any previous formal hospital work experience. Participation was voluntary and participants were informed that privacy and anonymity would be maintained. There are 18 items in the TSSNGN, so the estimated sample size would be between 90 and 180 participants. Considering the expected completion rate of 85%, this study requires a total sample size of 327 participants.
The TSSNGN consists of six topic domains that include 18 items: Y1–conflict between theory and practice (three items); Y2–excessive workload (four items); Y3–loss of social support (two items); Y4–shrinking relationship with colleagues (three items); Y5–confusion of professional nursing values (four items); and, Y6–incongruity between work and personal life (two items). There are four options for each item: “strongly disagree = 1”, “disagree = 2”, “agree = 3”, “strongly agree = 4”. Overall scores on the scale range from 18 to 72, with higher scores indicating greater impact on job transitions. In the current study, Cronbach's alpha was 0.92.
The full 14-item version of the Perceived Stress Scale includes two subscales: the negativity subscale (7 items) and the positivity subscale (7 items), which was one of the most widely used instruments for measuring perceived psychological stress [16]. Participants were asked to rate the frequency with which they experienced stressful situations over the past month on a five-point scale from 0 (never) to 4 (very frequent), with higher scores indicating greater stress. The Chinese PSS-14 showed good reliability and validity in the general population. In this study, the internal consistency was Cronbach's alpha = 0.90.
Permission to use the English version of the TSSNG was obtained from Kim, and the scale was then translated into Chinese according to the Intercultural Adaptation Process of Beaton and colleagues [17]. According to the tool translation and application guidelines for applying English tools in other cultures, the original text was translated in four steps following a translation-back-translation procedure [18]. The translation process included a doctor of nursing with overseas study experience and a Chinese English teacher. The researcher and two translators participated in discussions and consultations to develop a preliminary version of the scale. A draft of the scale was submitted for review by a doctorally prepared associate professor of nursing. Two bilingual (Chinese and English) nurses who had never been exposed to the scale completed the forward translation independently. After the translation was completed, the four-person translation team revised it and formed the preliminary scale of the Chinese version. Nursing professors reviewed the translation by comparing it to the original to determine if the translated version was appropriate. A psychology professor, 6 clinical nursing specialists, and an associate professor with years of experience in nursing education were invited by email to evaluate the validity of the scale. The group held at least a bachelor's degree, were experienced in clinical and practical settings, and understood the research process. Ten new nurses from a hospital in Wuhan who met the inclusion and exclusion criteria were selected for a preliminary investigation. From their interviews, we uncovered misunderstood words and phrases. The items were changed as needed to form the final Chinese version of the TSSNGN, which was then used for validation.
For content validity, the assessment scale was measured by the content experts. Content validity was completed by 6 experts in related fields, who were two clinical nursing specialists, two nursing educators and two bilingual experts. The demographic characteristics of the six members met the following criteria: (1) bachelor degree or above, (2) associate senior title or above, (3) having rich clinical practice experience or nursing knowledge. The experts rated the relevance and clarity of each item of the tool separately using a 4-point Likert scale: irrelevant, litter-relevant, relevant, and highly relevant were rated 1, 2, 3, and 4, respectively. The content validity index (CVI) was calculated at the item level (I-CVI), with a recommended value greater than 0.78 [19].
To define the content of the TSSNGN, a preliminary survey was conducted with 10 new nurses, representing 10% of the sampled population. The survey confirmed that there were no difficult or incomprehensible items in the questionnaire. Thus, we decided that the translated questionnaire would be used.
Nurses working at Zhongnan hospital of Wuhan University were recruited through an online questionnaire link found on Wenjuanxing, a professional online questionnaire survey, assessment and voting platform. The link allowed nurses to give informed consent prior to being allowed to proceed to the survey. A socio-demographic questionnaire developed by researchers was included and participants completed it prior to proceeding to the TSSNGN. A total of 374 questionnaires were collected, of which 47 were engaged in nursing work for more than one year. Thus, the final number of completed surveys was 327.
SPSS 23.0 [20] and AMOS 23.0 statistical programs were used to analyze the collected data. The data were presented as mean ± standard deviation (SD) and percentage (%) for general characteristics of the participants. The method of calculating the content validity index (CVI) was used to examine the quantitative content validity of the TSSNGN. Construct validity was established through the confirmatory factor analysis (CFA) method for the items in each subcategory by the structural equation model in this study. CFA was performed on 327 participants to confirm whether the extracted factor structure fit the data well. The following metrics determine the fitted model: χ2, ratio of chi-square statistic to degrees of freedom (χ2/df) < 3; root mean square error of approximation (RMSEA) of 0.08 or lower; root mean square residual (RMR) of 0.05 or less; goodness of fit index (GFI), incremental fit index (IFI), Tucker–Lewis index (TLI), and comparative fit index (CFI) of 0.90 or higher were considered to indicate a good fit [21]. In addition, the convergence validity was analyzed by Average Variance Extraction (AVE) and Composite Reliability (CR). The discriminant validity was analyzed using the square root of AVE and the Pearson correlation coefficient between AVE and other indexes. To verify the criterion-related validity, criterion validity was analyzed based on the correlation with perceived psychological stress using Pearson’s correlation. Finally, to verify the reliability of the TSSNGN, Cronbach's alpha value was used to confirm its internal consistency.
3.1 Socio-demographic characteristics of the participants
As to gender, male accounted for 14.37% and female accounted for 85.63%. The mean age was 21.97 years (SD = 1.54) ranging from 19 to 29 years. As to the educational background, most of them (51.37%) were university graduates, followed by those having completed junior college (39.76%), and graduates with master’s degrees or above (8.87%), respectively. There were vast majority of participants (79.20%) could choose nursing at first. The average score of each dimension ranged from 4.87 to 9.97, and the average score on the TSSNGN was 44.75 (SD = 8.23) (See Table 1).
Table 1
Socio-demographic characteristics of participants （n=327）
|
Characteristics |
|
n(%) |
Mean (SD) |
|
Gender |
Male |
47（14.37） |
|
|
|
Female |
280（85.63） |
|
|
Age (in year) |
|
|
21.97（1.54） |
|
Education level |
Junior college |
130（39.76） |
|
|
|
University |
168（51.37） |
|
|
|
Master’s degree or above |
29（8.87） |
|
|
If you have any brothers or sisters |
Yes |
116（35.47） |
|
|
|
No |
211（64.53） |
|
|
Marital status |
Single |
322（98.47） |
|
|
|
Married |
5（1.53） |
|
|
Was nursing your first choice? |
Yes |
259（79.20） |
|
|
|
No |
68（20.80） |
|
|
service relations |
staffing of public institution |
32（9.79） |
|
|
|
Contract |
295（90.21） |
|
|
Score of Y1 |
|
|
7.37(1.65) |
|
Score of Y2 |
|
|
9.91(1.85) |
|
Score of Y3 |
|
|
5.01(1.6) |
|
Score of Y4 |
|
|
7.61(1.82) |
|
Score of Y5 |
|
|
9.97(2.47) |
|
Score of Y6 |
|
|
4.87(1.31) |
|
Score of TSSNGN |
|
|
44.75(8.23) |
3.2 Validity and reliability of the instrument
3.2.1 Content validity
The content validity testing expert panel consisted of six people. In summary, the score of I-CVI (Item Content Validity Index) was 0.83-1.0 and the S-CVI (Scale Content Validity Index) was 0.92. It met with Lynn’s [19] criteria (a minimum I-CVI of .78 for 6 to 10 experts) and it had an S-CVI/Ave of 0.90 or higher and had good content validity. Thus, all 18 items were selected in the final questionnaire.
3.2.2 Construct validity
For all 18 items in the preliminary Korean version, six factors were used. Confirmatory factor analysis (CFA) was performed on the TSSNGN items. The Chinese TSSNGN followed the division established by the original version. The parameter estimates of the CFA of the Chinese version of the TSSNGN are shown in Figure 1. Examination of normalized factor loadings for 18 items was determined to be 0.51-0.85. The entire standardized factor loading was statistically significant and all the item was more than the minimum standard of 0.50. All the items loaded significantly onto their respective factors. The results showed that the non-standardized value of C. R was ranged 8.10 to 18.79, which satisfied the analytical condition above 1.96 (see Table 2).
CFA was done on these items. The model fit indexes were as follows: The c2 value of the 18 items in Model 1 was 463.57 (df = 120, p < 0.001), indicating that the p value was less than 0.05. Since the c2 value increases with the sample size, the correct c2 value can only be obtained if the sample size is appropriate. Because in this study, the confirmation of the model fit by c2/df was 3.86, which failed to meet the acceptability criterion of 3 or less. Meanwhile, the model fit indexes were CFI = 0.88, GFI = 0.85, IFI = 0.89, TLI = 0.85, RMR = 0.05, and RMSEA = 0.10, which did not meet the standard and should be adjusted. Therefore, Model 4 was constructed after three adjustments by applying the Modified Index (MI). The fitness analysis of model 4 showed that c2/df =3.09, RMSEA =0.07, RMR =0.03, GFI =0.90, IFI =0.92, TLI =0.90, and CFI =0.92, which was deemed relatively good by improving all fit of the model (see Table 3).
Table 2
Analysis of convergent validity of items
|
|
Items No. |
B |
SE |
β |
C.R. |
P |
CR |
AVE |
Cronbach’s |
|
Y1 |
1 |
1.00 |
- |
0.63 |
- |
<0.001*
|
0.71
|
0.45
|
0.79
|
|
2 |
1.25 |
0.15 |
0.80 |
8.26 |
|||||
|
3 |
1.29 |
0.16 |
0.57 |
8.25 |
|||||
|
Y2 |
4 |
1.00 |
- |
0.64 |
- |
<0.001*
|
0.69
|
0.37
|
0.64
|
|
5 |
0.73 |
0.09 |
0.51 |
8.10 |
|||||
|
6 |
0.77 |
0.09 |
0.54 |
8.29 |
|||||
|
7 |
0.76 |
0.09 |
0.57 |
8.40 |
|||||
|
Y3 |
8 |
1.00 |
- |
0.73 |
- |
<0.001*
|
0.70
|
0.50
|
0.67
|
|
9 |
0.99 |
0.08 |
0.69 |
12.02 |
|||||
|
Y4 |
10 |
1.00 |
- |
0.85 |
- |
<0.001*
|
0.79
|
0.57
|
0.79
|
|
11 |
0.92 |
0.07 |
0.74 |
13.95 |
|||||
|
12 |
0.82 |
0.06 |
0.65 |
12.97 |
|||||
|
Y5 |
13 |
1.00 |
- |
0.83 |
- |
<0.001*
|
0.89
|
0.66
|
0.89
|
|
14 |
0.88 |
0.06 |
0.77 |
15.40 |
|||||
|
15 |
1.05 |
0.06 |
0.83 |
18.79 |
|||||
|
16 |
1.05 |
0.06 |
0.81 |
18.07 |
|||||
|
Y6 |
17 |
1.00 |
- |
0.78 |
- |
<0.001*
|
0.77
|
0.62
|
0.77
|
|
18 |
1.04 |
0.07 |
0.80 |
14.83 |
*p<0.05.
Table 3
Analysis of construct validity
|
|
χ2(p) |
df |
CIMIN/df |
GFI |
IFI |
TLI |
CFI |
RMSEA |
RMR |
|
Model 1 |
463.57* |
120 |
3.86 |
0.85 |
0.89 |
0.85 |
0.88 |
0.10 |
0.05 |
|
Model 2 |
416.32* |
119 |
3.50 |
0.86 |
0.91 |
0.88 |
0.90 |
0.09 |
0.04 |
|
Model 3 |
394.01* |
118 |
3.34 |
0.87 |
0.91 |
0.89 |
0.91 |
0.08 |
0.04 |
|
Model 4 |
361.50* |
117 |
3.09 |
0.90 |
0.92 |
0.90 |
0.92 |
0.07 |
0.03 |
*p<0.05.
3.2.3 Convergent validity
According to Fornell and Larcker [22], there were three methods to test the convergent validity: the standardized factor loading, AVE and CR [23] considered that the standardized factor loading of each item should not be less than 0.50, or the factor load of each item was statistically significant. And then the scale could be considered to have convergent validity if either of the two conditions was met. The standardized factor loadings for the 18 items ranged from 0.51 to 0.85, with each item greater than 0.50. Therefore, it was confirmed that the standardized factor loadings in this study met the criteria for all items.
The AVE was 0.37~0.66 in Table 2. Generally speaking, AVE was higher than 0.5, but 0.4 is acceptable. Because it was said that if AVE was less than 0.5, but the composite reliability is greater than 0.6, the convergent validity of the construct was still sufficient according to Lam [24]. CR should be 0.70 or higher [25]. The CR was 0.69~0.89 in this study, meeting the minimum criteria. Therefore, since the TSSNGN met the minimum criteria for standardized factor loading, AVE, and CR, the convergent validity of the items measuring the transition shock experience of newly graduated Chinese nurses was confirmed (see Table 2).
3.2.4 Discriminant validity
To verify the discriminant validity of the TSSNGN, firstly, the six latent variables constituting the concept should be significant; secondly, the correlation coefficient should be less than 0.50; finally, the correlation coefficient should be less than the square root of AVE. In this study, the six factors were significantly correlated (p<0.05). The AVE of Y1 to Y6 was 0.45, 0.37, 0.50, 0.57, 0.66 and 0.62, respectively (see Table 2). The AVE square root of Y1 to Y6 was 0.67, 0.56, 0.71, 0.75, 0.81 and 0.79, Correspondingly (see Table 4), which all correlation coefficients were less than the AVE square root, indicating that each latent variable had a certain correlation with each other and a certain degree of differentiation, thereby confirming discriminant validity in this scale (see Table 2 and 4).
Table 4
Analysis of criterion-related validity
|
|
Y1 |
Y2 |
Y3 |
Y4 |
Y5 |
Y6 |
|
Y1 |
1 |
|
|
|
|
|
|
Y2 |
0.10* |
1 |
|
|
|
|
|
Y3 |
0.08* |
0.16* |
1 |
|
|
|
|
Y4 |
0.13* |
0.18* |
0.28* |
1 |
|
|
|
Y5 |
0.10* |
0.17* |
0.26* |
0.30* |
1 |
|
|
Y6 |
0.10* |
0.16* |
0.25* |
0.27* |
0.32* |
1 |
|
Square root of AVE |
0.67 |
0.56 |
0.71 |
0.75 |
0.81 |
0.79 |
*p<0.05.
3.2.5 criterion-related validity
Stress perception has a certain positive effect on the pressure caused by people entering a new environment. To test the criterion-related validity, we analyzed the correlation between the Chinese version and perceived stress. Generally, a correlation of 0.40-0.80 is recommended when testing the criterion-related validity. Analysis showed that the scale of TSSNGN and PSS had statistically significant positive (+) correlation (r=0.97, p<0.01). In addition, the scale of TSSNGN showed significant positive (+) correlations, specifically PSS-1 (r=0.88, p<0.01), PSS-2 (r=0.93, p<0.01). Moreover, the correlation coefficients of all factors in the scale ranged from 0.43 to 0.93. Therefore, it could confirm the criterion-related validity of the Chinese version of the PSS (See Table 5).
Table 5
Analysis of criterion-related validity of the Chinese TSSNGN and PSS
|
Scales |
Y1 |
Y2 |
Y3 |
Y4 |
Y5 |
Y6 |
Total of TSSNGN |
PSS-1 |
PSS-2 |
Total of PSS |
|
Y1 |
1 |
|
|
|
|
|
|
|
|
|
|
Y2 |
0.44* |
1 |
|
|
|
|
|
|
|
|
|
Y3 |
0.28* |
0.59* |
1 |
|
|
|
|
|
|
|
|
Y4 |
0.39* |
0.59* |
0.70* |
1 |
|
|
|
|
|
|
|
Y5 |
0.31* |
0.61* |
0.67* |
0.69* |
1 |
|
|
|
|
|
|
Y6 |
0.31* |
0.57* |
0.67* |
0.63* |
0.79* |
1 |
|
|
|
|
|
Total of TSSNGN |
0.57* |
0.61* |
0.63* |
0.85* |
0.88* |
0.82* |
1 |
|
|
|
|
PSS-1(The negativity subscale) |
0.80* |
0.66* |
0.65* |
0.75* |
0.69* |
0.63* |
0.88* |
1 |
|
|
|
PSS-2(The positivity subscale) |
0.43* |
0.87* |
0.79* |
0.81* |
0.79* |
0.72* |
0.93* |
0.78* |
1 |
|
|
Total of PSS |
0.62* |
0.83* |
0.77* |
0.83* |
0.79* |
0.72* |
0.97* |
0.96* |
0.92* |
1 |
*p<0.01.
3.2.6 Reliability
The Cronbach's alpha of the six factors in the 18-item Chinese version were 0.79, 0.64, 0.67, 0.79, 0.89 and 0.77, respectively. The total scale was 0.92 (see Table 2)
The aim of the current study was to test the reliability and validity for the Korean version of the TSSNGN among newly graduated Chinese nurses. Psychometric tests showed that each item of the translated scale had a good degree of discrimination in Chinese nurses. 327 participants were investigated and the data were analyzed. The results showed that the 18-item TSSNGN high construct validity and internal reliability. The tool provides essential data on newly graduated nurses for use by nurse administrators in employment settings.
Generally speaking, validation studies should be used multiple analyses to provide significant conclusion to recommend the use of the specified instrument in clinical situation. Therefore, the multiple methods were used to analyze in this study: content, construct, and criterion. The S-CVI and I-CVI for this scale were high, which met the criteria provided by the research [26], indicating that the experts agreed that the items were suitable and relevant to assess the transition shock experienced among newly graduated nurses. The results showed that the correlation coefficient between each item and the total score had appropriate content validity. Discriminant validity, factor structure and convergent validity were reconfirmed by CFA. The measurement equivalence of the Korean TSSNGN was verified by CFA and the results demonstrate the appropriate applicability of the factor structure model, thus confirming its construct validity.
The criterion validity of the Chinese TSSNGN was also tested in this study. A gold standard with the identical construct as the translated instrument for which the larger the correlation coefficient means the better the validity of the research tool should be used to test the criterion validity [27], but no such instrument was available in this study [14]. Previous studies have suggested that if there was no recognized "gold standard" tool, autonomous rating could also be used [28], and a standard correlation validity of 0.40 ~ 0.80 was feasible [29]. Significant correlations with both the Chinese TSSNGN and PSS were found, which the criterion validity of this study was 0.43 ~ 0.93. There was a close relationship between the perceived stress and stress conflict of new nurses in the workplace. It means if a person does not deal with stress, it may lead to conflicts and problems. Therefore, the Chinese TSSNGN was considered a useful tool to measure the contents of the conflicts and transition shock of newly graduated nurses.
A validity assessment suggested that correlation coefficients of 0.60 ~ 0.80 indicated “high validity" and one of 0.80 ~ 1.0 indicated “very high validity” [30]. Therefore, the TSSNGN proved to be an effective instrument for evaluating transition shock among newly graduated Chinese nurses. In this study, Cronbach's alpha was used to measure the internal consistency of the Chinese version of TSSNGN, ranging from 0.64 to 0.89. The Cronbach’s alpha of the integrated tool was 0.92, which was consistent with the Cronbach’s alpha of 0.89 for the original tool [15], indicating that the scale had high reliability in Chinese culture.
In a word, there is sufficient reliability and validity evidence to support the use of the Chinese TSSNGN in newly graduated Chinese nurses. It can offer an opportunity to explore the participants’ experience of evaluating transition shock in a Chinese context.
However, the current study had certain limitations. This research used convenience sampling and was conducted in one hospital in Wuhan in HuBei province. Thus, the generalizability of findings to different regions and cities is limited. So, more studies are essential to expand the employment of this tool. The sample size should be expanded to adopt multi-stage stratified sampling in other cities and regions in China. Since the TSSNGN evaluated in this study was analyzed according to the sub-factors organized by the developer, there may be limitations in evaluating subjects in the Chinese culture. Further research is needed to explore this concept. Validation testing for the TSSNGN requires the use of a validated gold standard scale. For this study, there was no gold scale for concurrency effectiveness tests that could be used. Therefore, alternative scales should be considered for analysis.
The TSSNGN, developed by Kim and colleagues, was translated and its validity and reliability tested for use in assessing transition shock in newly graduated Chinese nurses working in Chinese clinical facilities. The result of the study confirmed sufficient validity and reliability for the 18 items and six dimensions. This instrument provides nurse leaders, managers and nurse educators in schools of nursing with an easily applicable tool for evaluating the impact of new nurses in the initial stage of transition. This is the first study to verify the validity and reliability of the Korean TSSNGN in China, and the tool could be used in the future. In giving the corresponding social and organizational support, it could maintain the stability and improve the overall quality of the nursing team in a practice setting.
TSSNGN：Transition Shock Scale for Newly Graduated Nurses
PSS：Perceived Stress Scale
CVI：content validity index
I-CVI：item content validity index
CFA：confirmatory factor analysis
RMSEA：root mean square error of approximation
RMR：root mean square residual
GFI：goodness of fit index
IFI：incremental fit index
TLI：Tucker–Lewis index
CFI：comparative fit index
AVE：Average Variance Extraction
CR：Composite Reliability
MI：Modified Index
Ethics approval and consent to participate
The study was conducted according to the guidelines of the Declaration of Helsinki, and approved and approved by Ethics Committee of Wuhan University School of Medicine (NO.2021YF0014). Informed consent was obtained from all subjects involved in this study.
Consent for publication
Not applicable.
Availability of data and materials
The datasets used during the study are available from the corresponding author upon reasonable request.
Competing interests
All the authors declare no conflict of interest.
Funding
This work is supported by the 2019 Teaching Reform Project of Wuhan University Health Science Center（2019061), the key research project of Jiangsu Vocational Institute Of Commerce（JSJM19011）and leading talent project of Jiangsu Vocational Institute of Commerce.
Authors’ Contributions
All authors have full access to all the data in this study and take responsibility for the integrity of the data and the accuracy of the data analysis. LD, QZ, BLF and DL designed the study and wrote the research protocol. LD, SF, JXZ, FH, JC, QZ, BLL, BLF, and DL managed the field survey, quality control and statistical analysis and prepared the manuscript draft. QZ, BLF and DL contributed to in-depth revisions of the manuscript. LD, SF, JXZ, QZ, BLF and DL supervised the survey and checked data. LD, SF and JXZ contributed equally to this manuscript.
Acknowledgments
The authors gratefully acknowledge the cooperation of all the participants in this study. Sincere thanks are given to Dr. Sharon R. Redding (EdD, RN, CNE) for assistance in editing.