Discrepancy between the Image Held by Nursing Students of Themselves as Employed Nurses during the Pre-Employment Period and the Post-Employment Reality Faced by Novice Nurses ()
1. Introduction
With medical care in Japan becoming increasingly sophisticated and complex in recent years, the need is surging for highly skilled nursing personnel. The rapid aging of the Japanese population further makes the issue of securing nursing personnel a matter of urgency. Under these circumstances, a report by the Director of the Medical Affairs Bureau of the Ministry of Health, Labour and Welfare, the Seventh Study Report on the Supply-Demand Outlook for Nursing Personnel, [1] states that the demand for nursing personnel is exceeding the supply, making it essential to further promote measures to secure nursing personnel, including by enhancing retention, training, and re-employment support. Meanwhile, a survey conducted by the Japan Nursing Association on hospital nursing [2] reported that the nursing staff turnover rate in FY2021 was 10.6% for all nurses and 8.2% among new graduates, while the turnover rate for new graduate nurses in FY2020 and FY2019 was 8.6%, indicating that the turnover of new graduate nursing staff remained almost the same.
In a literature review by Uchino et al. [3] , “reality shock” was the most frequent topic brought up by novice nurses as an influencing factor of turnover. Dean et al. [4] defined occupational reality shock as “the difference between an individual’s expectations of work formed before joining an organization and their perception of work after becoming an organizational member”. This anticipatory socialization stage precedes the actual belonging to an organization, and nursing students who have yet to be employed are at this stage. According to Feldman [5] , anticipatory socialization is the process by which organizational members acquire the knowledge and understanding of organizational culture and values, or the skills necessary to fulfill their roles, through organizational socialization during the period prior to actual organizational entry. To prevent new graduate nurses from leaving the workforce, it is important for this anticipatory socialization stage to play a role in facilitating socialization after organizational entry. This requires that potential employees acquire expectations regarding organizational entry during this anticipatory stage that are shaped by images that are close to reality. Nursing is a professional occupation, and in order to qualify as nurses, students learn not only through lectures but also clinical practice on campus and on-site in hospitals. Clinical training, thus, provides nursing students with opportunities to build their image of the nursing profession and work.
However, the number of total educational hours for nurses decreased from 5077 hours in 1951—when the Regulations for Designation of Training Schools for Public Health Nurses, Midwives, and Nurses were established—to the current 3000 hours (related to the fourth revision of the curriculum). This led to a significant decrease in clinical practice hours—from 3927 to 1035 hours—meaning that the amount of practice of nursing skills has been restricted, which may have an impact on patient safety [6] . In addition, for patients to be treated by a nursing student they must provide consent; thus, the patients that nursing students usually care for are those who are already favorable toward receiving care from students. This context suggests that nursing students may be experiencing a lack of information and experience regarding clinical practice under the current conditions of the Japanese nursing curriculum, hindering their ability to form a realistic image of nursing work. Additionally, when selecting a hospital to work as a nurse, students’ gathering of information about the target hospital and observation of nurses at work in this hospital during their internships supplement their building of the image of nursing work. However, with regard to information gathering when selecting a hospital for employment, individuals are free to do so, and the information obtained varies from one individual to another. Considering these delineations, we hypothesized that the image that nursing students hold of themselves as employed nurses immediately before their actual employment—in this study, the period between when nursing students decide on a job and when they start working as nurses in a healthcare institution—and the reality of the work may diverge.
Therefore, this study aimed to clarify the differences between the images that nursing students hold of themselves as employed nurses during the period immediately before employment and the reality that nurses find after actual employment (i.e., in this study, generally within one year of the first day of employment). By clarifying this discrepancy, we believe that this study provides evidence highlighting the opportunities to enhance basic nursing education and potential content that nursing students should receive education on regarding the reality of nurses’ work in real clinical settings. The study also delivers reference data that may show and support the importance of information gathering regarding the place of employment by nursing students to promote well-informed employment decision-making, which may then increase positive anticipatory socialization and reduce job turnover among novice nurses.
2. Aims
The purpose of this study is threefold, as follows.
Research Objective 1: The period of time between when a nursing student decides where to work and when they start working is defined as the period immediately before employment. This study clarifies the image that nursing students have of themselves working and living as nurses after employment during the period just prior to employment.
Research Objective 2: To clarify the image nurses have of themselves in the reality of working as a nurse after employment.
Research Objective 3: To compare the image nurses have of themselves as employed nurses immediately prior to employment with their actual image of themselves after employment as nurses, and clarify the differences between the two.
3. Methods
3.1. Subjects and Data Collection Methods
This study adopted a conventional qualitative content analysis approach.
3.1.1. Nursing Students’ Image of Themselves before Employment
The inclusion criteria for the participants were that they were senior nursing students from nursing colleges who were expected to graduate from college and start working as nurses at hospitals in the coming year. Eight students participated in this study. To clarify the image that nursing students have of themselves as employed nurses just prior to employment, we considered only conducting interviews with nursing students who had received offers of employment. However, nursing students would be limited to the image they had at the time the interview was conducted, and the content of the images they had in the period between the interview and employment may have been missing. To compensate for the missing image data during this period, nurses within two years of graduation were asked to reflect on their time as students and were interviewed on the same topics (see Section 3.1.2.). A research cooperation request form was distributed to fourth-year nursing students at one nursing college in a certain prefecture. Students who were willing to participate were asked to contact the principal investigator via e-mail or phone. Those who were willing to participate were asked to contact the principal investigator by e-mail or phone. For the semi-structured interviews, an interview guide was developed based on the purpose of this study—focusing on questions related to the nursing students’ post-employment self-image. The semi-structured interviews were conducted in a quiet, private room and lasted 30 - 60 minutes. They were conducted using the interview guide and depending on the participants’ responses, more detailed questions were asked when there was a need to gain further understanding. Data collection was completed between October 2018 and October 2019.
3.1.2. Nurses’ Image of Themselves after Employment
The nurse participants in this study were 10 nurses working in a hospital within two years of their graduation. The hospital director and the head of the nursing department of a hospital in a certain prefecture informed participants of the study aims and ethical considerations in writing and orally. Those who were willing to participate were asked to contact the principal investigator by e-mail or phone. These 10 nurses were additionally asked about their real image of themselves after employment during the semi-structured interviews, as well as their image of themselves immediately before employment. The data collection period was from July to August 2019.
3.1.3. Discrepancy between Nurses’ Image of Themselves Immediately before and after Employment
We compared the results of the analysis of nurses’ image of themselves immediately before and after employment and examined the differences between the two. We then examined why these differences arise and how they should be addressed in order to minimize them.
3.2. Data Analysis
Data analysis was conducted using qualitative content analysis based on the methods used in a prior study [7] . The content obtained from the semi-structured interviews was recorded verbatim, and content corresponding to the image that participants held of themselves as employed nurses during the period immediately before employment were extracted and coded. The differences and similarities between the codes were compared and analyzed, based on which subcategories and categories were extracted. The extracted categories were further integrated to determine the core categories. The validity and rigor of the analysis were ensured by requesting researchers with experience in qualitative research to review all the analyzed data.
3.3. Ethical Considerations
Those who indicated their willingness to participate were then explained the purpose of the study and ethical considerations in writing and orally. Study participants received oral and written explanations on the following topics: study purposes, voluntary participation, that there would be no disadvantage for them if they participated in the study or withdrew their participation during any stage, that the data would not be used for any purpose other than that of this study, and that the data would be published in journals and presented at academic conferences anonymously, with participants being assigned numbers/letters to protect their personal information. After these explanations, written consent was obtained from all participants. The interviews were recorded using an IC recorder with the permission of the participants. The interview recordings and verbatim transcripts were stored in a locked cabinet. This study was approved by the Ethics Committee of Kawasaki University of Health and Welfare (approval number: 18-033).
4. Results
The 18 subjects in this study included eight fourth-year students who were enrolled in nursing college and had received offers of employment as nurses, and 10 nurses who were working in hospitals within two years of graduation. Their details are shown in Table 1.
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Table 1. Overview of research subjects.
4.1. Nursing Students’ Image of Themselves after Employment
Four core categories, 25 categories, and 72 subcategories were extracted from the analysis of the image that the participants held of themselves as employed nurses during the period immediately before their employment. The core categories are denoted below by [ ], categories are denoted by << >>, and the participants’ narratives are indicated by “ ”.
The core categories identified were [Life after employment], [Adaptation to work], [Adaptation to the workplace], and [Career foundation building]. The details of the core categories, categories, and subcategories are listed in Table 2.
4.1.1. Life after Employment
The six categories of [Life after employment] were as follows: << Living in the area of my choice >>, << Living a work-centered life >>, << Balancing work and personal life >>, << Working in an ideal work environment >>, << Working irregular shifts >>, and << Physically adapting to shift work >>.
An example of participants’ narratives about the category << Balancing work and per sonal life >> was:
“This is my first time living on my own, so I’m worried about whether I’ll be able to cope with it and whether I’ll be able to endure it psychologically as a new member of society. But I have a strong feeling that I have to do it.” (Nursing student C)
An example of participants’ narratives about the category << Living a work-centered life >> was:
“When I was deciding where to work, whether I could get much time off or not was really a secondary priority. I wanted to work the night shift as much as I could.” (Nursing student D)
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Table 2. The image held by participants of themselves as employed nurses during the period immediately before employment.
4.1.2. Adaptation to Work
The core category [Adaptation to work] consisted of the following eight categories: << Learning nursing skills with which I have no experience >>, << Acquiring nursing skills on the job >>, << Learning my job under the guidance of my seniors >>, << Learning job fundamentals through novice training >>, << Facing the rigors of the job >>, << Persevere even when assigned to a department I don’t want to be in >>, << Practicing nursing tasks that I did not have much experience with as a student >>, and << Delivering nursing care for patients with confidence >>.
An example of participants’ narratives about the category << Acquiring nursing skills on the job >> was:
“When I went to the job fair, I was told that if I had any concerns about my technique, senior nurses would guide me during my practice sessions in the practice area set up in the hospital.” (Nursing student G)
4.1.3. Adaptation to the Workplace
The core category [Adaptation to the workplace] comprised seven categories, as follows: << Nurses working together as a team >>, << Working in a good work culture >>, << Familiarizing with the nursing community >>, << Working with more strict senior nurses >>, << Being treated as a fellow nurse, not a student >>, << Working together with fellow nurses in friendly competition >>, and << If I don’t fit in, the nursing department will be there to help me >>.
An example of participants’ narratives about the category << Familiarizing with the nursing community >> was:
“I have some concerns about working in a society with a lot of women, regarding human relations.” (Nurse H)
4.1.4. Career Foundation Building
Regarding the core category [Career foundation building], the following four categories were extracted: << Going through phases and becoming independent >>, << Overcoming the novice period >>, << Developing expertise in the desired area >>, and << Orienting one’s career while in the workplace >>.
An example of participants’ narratives about the category << Developing expertise in the desired area >> was:
“When I went on a tour of the hospital where I was going to work, I thought that I would be able to improve my knowledge and skills at this hospital and provide better nursing care.” (Nursing student E)
4.2. Nurses’ Image of Themselves in Reality after Being Employed as Nurses
From the analysis of the interviews with the 10 nurse participants about the reality of their post-employment image of themselves, 14 categories and 33 subcategories were extracted.
These categories and subcategories were then classified into one of the aforementioned four core categories extracted from the data on the image that participants held of themselves as future employed nurses during the period immediately before employment: [Life after employment], [Adaptation to work], [Adaptation to the workplace], and [Career foundation building]. The details of the categories and subcategories are presented in Table 3.
4.2.1. Reality of Life after Employment
The following six categories related to the reality that nurses found after employment were classified under the core category [Life after employment]: the negative categories included << Cannot physically and mentally adapt to the life changes >>, << Confused by the complexity of the work shifts >>, << Night shifts are a great burden on the body >>, and << Confused by the reality of how nurses work >>; and the positive categories included << Can use the free time available from shift work effectively >> and << Will have more financial freedom >>.
An example of participants’ narratives about the category << Night shifts are a great burden on the body >> was:
“The night shift is so hard. I’ve only done it twice, but the way I work, or rather the flow of work, is totally different from the daytime, so I’m struggling to keep up.” (Nurse I)
4.2.2. Reality of Adaptation to Work
The following five categories were extracted from the reality that nurses faced upon being employed and were assigned to the core category [Adaptation to work]: << Being asked to do more than I am capable of >>, << Always having to do more than I have time for >>, << Having to perform unexpected tasks >>, << Don’t have the time to get involved with my patients the way I’d like >>, and << Feeling the weight of responsibility as a nurse >>.
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Table 3. Nurses’ image of themselves in reality after being employed as nurses.
An example of participants’ narratives about the category << Always having to do more than I have time for >> was:
“When I first started working, I had to take care of not only my own patients but also other patients, and my senior nurses were angry with me because I was too poor at time management.” (Nurse B)
4.2.3. Reality of Adaptation to the Workplace
Only one category pertaining to the reality found by nurses after they were employed was classified under the core category [Adaptation to the workplace], which was the positive category << Most people in the workplace are women, but they are easy to work with >>.
An example of participants’ narratives about the category << Most people in the workplace are women, but they are easy to work with >> was:
“I was most anxious about working in an office where there were many women. I was nervous, but everyone is quite friendly and the workplace is easy to work in, so I think I am having a good time.” (Nurse H)
4.2.4. Realities of Career Foundation Building
Only the following two categories regarding the reality found by nurses once they were employed were classified under the core category [Career Foundation Building]: << Experiencing depressing days due to not being assigned to the department of choice >> and << Not having time to think about my future career >>.
An example of participants’ narratives on the category << Not having time to think about my future career >> was:
“Right now, I feel like I’m so busy learning the job that I can’t think about my future career.” (Nurse A)
4.3. Discrepancies between the Participants’ Image of Themselves as Employed Nurses and the Post-Employment Reality
We compared the image of self-confidence that nursing students had immediately prior to employment with the image they had of themselves in reality after they start working as nurses. The results of the differences found are shown in Figure 1.
4.3.1. Life after Employment
Participants imagined that they would be able to << Balance work and private life >> once they found a job; however, in reality, they found that they << Could not physically and mentally adapt to the life changes >> as they began working as nurses. Participants also imagined << Working irregular shifts >> and stated that they could << Physically adapt to shift work >>. However, the reality felt by the nurse participants was that of being << Confused by the complexity of the work shifts >> and being << Confused by the reality of how nurses work >>, and that << Night shifts are a great burden on the body >>.
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Figure 1. Discrepancies between the participants’ image of themselves as employed nurses and the post-employment reality.
4.3.2. Adaptation to Work
Many of the interviewees described having images of themselves as employed nurses that were related to the following categories under the core category [Adaptation to work]: << Learning nursing skills with which I have no experience >>, << Acquiring nursing skills on the job >>, << Learning my job under the guidance of my seniors >>, and << Learning job fundamentals through novice training >>. Nonetheless, three of the categories related to the reality that nurse interviewees found once they were employed: << Being asked to do more than I am capable of >>, << Having to perform unexpected tasks >>, and << Always having to do more than I have time for >>. Additionally, interviewees believed that they would be able to deliver care with confidence after they were employed. Nonetheless, the reality described by nurse interviewees was reflected in the categories << Don’t have the time to get involved with my patients the way I’d like >> and << Feeling the weight of responsibility as a nurse >>.
4.3.3. Adaptation to the Workplace
The image of adaptation to the workplace was one of being able to break into a team in the workplace, including categories such as << Nurses working together as a team >>, << Working in a good work culture >>, << Familiarizing with the nursing community >>, and << Working with more strict senior nurses >>. However, the only reality that was suggested regarding easy to work with.
4.3.4. Career Foundation Building
In forming the foundation of their careers, the nursing students imagined that they would be << Orienting one’s career while in the workplace >>; the reality was << Not having time to think about my future career >> and << Experiencing depressing days due to not being assigned to the department of choice >>.
5. Discussion
5.1. Nursing Students’ Image of Themselves after Employment
This section discusses the characteristics and considerations for each core category related to the nursing students’ image of themselves after employment.
5.1.1. Life after Employment
In terms of the characteristics of the images that nursing students held of themselves as employed nurses immediately before they were actually employed, they were generally related and limited to the images they constructed by observing the workplace atmosphere, shift work, and job content of nurses during clinical practice. It may be that the students were able to imagine themselves as employed nurses in a similar fashion as what they had observed during on-site clinical practice because they were able to overlap these observations with their expectations for themselves after they were employed. However, they did not have a clear image of the tasks that nurses are required to do that were not related to their clinical practice sessions. Furthermore, during clinical practice, the students were likely so occupied with their own affairs that they did not construct a clear image of the specific work system, job descriptions, and chores of nurses, which were difficult for them to see. Although the shadowing of nurses is sometimes performed during on-site clinical practice, this seemed to be insufficient to help students grasp the overall picture of nurses’ work.
5.1.2. Adaptation to Work
In Japan, nursing students often practice nursing skills related to daily living assistance, such as physical cleansing, together with professional nurses during their clinical training, enabling them to master these skills by the time they graduate. Nursing students’ imagined they would be confident in being able to perform all the nursing skills related to daily living assistance that they learned during their clinical practice when they were employed. Yet, students are not allowed to perform nursing tasks that are invasive to patients in clinical training due to patient safety issues. Due to this situation, students are unable to independently practice these nursing skills during clinical training and, thus, cannot perform them after they are employed due to a lack of experience. They may also feel anxious about practicing these nursing tasks. In addition, the nursing skills learned during college education are very basic and differ from those applied in clinical settings. Therefore, most novice nurses acquire the nursing skills that they do not learn through clinical practice only after employment.
Furthermore, nursing students described that they imagined that they would learn the skills that they had not experienced in clinical practice under the guidance of their seniors. Clinical training does not expose students to duties other than assisting with the patients they receive, and they rarely receive multiple patients or experience duties other than those related to assistance. Consequently, many hospitals have established systems, which participants knew of and talked about, in which senior nurses provide one-on-one guidance to novice nurses on both nursing skills and general nursing duties. This suggests that, rather than expecting to learn skills in which they were inexperienced before their graduation, they expected to receive technical training using the actual items and methods of the healthcare institution where they would be employed and under the guidance of their senior coworkers. All of this requires a high level of leadership skills from senior nurses: AS Porter, Lawler, and Hackman [8] state, an important influence on organizational socialization in the early years of organizational entry is the skills and attitudes of supervisors who supervise and guide new hires in the performance of their job duties. According to Ukawa [9] , in the nursing profession, group education and educational activities in the nursing department are both important for novice nursing staff to learn skills smoothly. The author explained that this is because learning nursing skills through these methods allows novice nurses to overcome the reality shock they may experience, and the methods promote organizational socialization among nurses.
The participants considered that training on nursing skills for new nurses was already provided in many hospitals as part of new nurse education, and this image was established by the fact that it is promoted at hospital information sessions to reduce nursing students’ anxiety. They also imagined that they would face difficult situations related to the job, such as being scolded by their seniors, feeling frustrated, and having a hard time due to the busy workload. Thus, the analysis suggests that another characteristic of nursing students is that they are prepared for the rigors of the job because they have seen clinical work during their on-the-job training. Participants also constructed an image that they would have to face the harder sides of the job once they became nurses, which was represented by the category << Facing the rigors of the job >>. Nonetheless, participants reported imagining that they would be capable of overcoming the novice period and be prepared for the difficult sides of the job. This image may have been created by students after having witnessed and learned about the rigors of the work and the harshness of the nursing profession during their clinical practice sessions.
5.1.3. Adaptation to the Workplace
Before selecting where they would like to work, participants reported gathering information on the potential hospital/institution through various means, including searching for information in pamphlets or on the Internet, getting information by directly contacting nurses working at the hospital/institution, looking at the relationships among nurses during the internship period, and observing the workplace atmosphere during their internships to confirm that it was a comfortable place to work. However, some students had the impression that the internship was designed to allow students to see only the good points of the place in order to attract them to work at the institution. Accordingly, some of the participants only chose to work at the hospital where they spent their internship based on the more realistic image they constructed after seeing the usual workplace atmosphere during their clinical practice. Wanous [10] found that a realistic job preview (RJP) prevents job turnover due to reality shock; that is, institutions can reduce reality shocks after employment and potentially decrease job turnover by providing reality-based information for potential employees during the recruitment process. Thus, instead of presenting only the good sides of the institution and its basic information during informational sessions, stakeholders could interweave these sessions with more realistic information that does not cause anxiety, thereby helping nursing students have a clearer image of themselves as future nurses employed in the institution when they are in the period immediately before employment and, thus, preventing reality shocks.
5.1.4. Career Foundation Building
Nursing students imagined that they would be able to work with veteran nurses and certified nurses, who they thought would have a broader perspective of the nursing field, and to orient their careers by referring to and working with these nurses. These images were formed because the nursing profession is a national certification and a profession that can be continued throughout one’s life.
5.2. Nurses’ Image of Themselves in Reality after Being Employed as Nurses
This section discusses the characteristics and considerations for each core category related to nurses’ image of themselves in reality after they were employed.
5.2.1. Reality of Life after Employment
New nurses often started to live alone at the same time as beginning their first nursing position, hindering their bodily adaptation to these life changes. They also experienced continuous tensions related to having to learn the perks of the new job, which led them to a state wherein they felt they could not physically nor mentally adapt to these changes. Moreover, although the nurse participants described that they understood that night shifts were a part of the nursing work schedule when they were still nursing students, they said that once they were employed, they could not imagine themselves working the night shift, and many felt uneasy before starting night shift duties because they had no idea what it would be like. It was also common for them to learn the details of complicated work schedules (e.g., staggered work hours in addition to the night shift) only after they started working, which sometimes left them confused about the work shifts.
As for the night shift, some felt physically drained because they could not finish their work by the end of the shift. Further, some often fell ill after working night shifts, thus describing that these shifts placed a great burden on their bodies. As aforementioned, the participants reported that they could not have imagined when they were students that the reality of nursing work would be what they faced when they were employed; thus, they reported that they were often befuddled by this reality. Notwithstanding, as they became accustomed to the shift work, they were able to take weekdays off and started to perceive that this work schedule allowed them to use their free time effectively. Since they were professional nurses, they were also often paid more than ordinary company employees, so they described feeling that their lives would be enriched by having more financial freedom. Thus, the results suggest that the shift work of nurses can be characterized not only as a disadvantage but also as an advantage once they become accustomed to it.
5.2.2. Reality of Adaptation to Work
Nursing students are generally expected to take care of only one patient during clinical practice, and they tend to experience the delivery of nursing care for multiple patients very sparsely—mostly during their last integrated training. However, as they became novice nurses, they were assigned to multiple patients, which created multiple tasks and required them to make quick decisions and actions while efficiently prioritizing which duties to tend to; thus, they reported feeling that they were asked to do more than what they could actually do. They further described being constantly under time pressure and being short of time, stating that they were not able to finish their tasks even as they continued working after their stipulated work hours. Moreover, the nurse participants had to perform tasks that they did not expect that nurses did when they were nursing students, such as duties other than those related to the patients they receive and clerical work, on a daily basis. As a result, participants reported being unable to deliver the fulfilling nursing care they were used to providing when they were students in clinical practice, which gave them the dilemma of wanting to get involved with patients but not being able to. Nurse participants also said that when they were called a “nurse” in the same way as their veteran peers, they felt the responsibility of the work, although they also perceived themselves as not being able to do some of the related tasks. Thus, the results suggest that the discrepancy between the on-site training participants experienced as nursing students and the actual work of nurses led to impatience and work dilemmas after employment.
5.2.3. Reality of Adaptation to the Workplace
According to the summary of the 2020 Health Administration Report (Employment Medical Personnel) [11] , though the number of male nurses in Japan is increasing, it remains at only 8.1%, and female nurses continue to dominate the workforce. Therefore, nurse participants reported not being able to imagine themselves in an environment filled with women, and feeling uneasy about working in such an environment. As they actually started working, they described that, indeed, the workplace was filled with women, but that working with them was generally a tranquil experience.
5.2.4. Realities of Career Foundation Building
The reality of the new nurses’ career foundations was that most of them were assigned to their desired department. However, in cases in which the newly employed nurses were not assigned to their desired departments, they experienced some “depressing days”, which was a major discrepancy from their previous image of their post-employment work and caused them to feel unhappy. In addition, the respondents thought that they would be able to direct their own careers while working after finding a job; in reality, they were so busy that they “did not have time to think about their future careers”.
5.3. Discrepancies between the Participants’ Image of Themselves as Employed Nurses and the Post-Employment Reality
This section describes the discrepancies between the participants’ image of themselves as employed nurses and the post-employment reality, as well as the support they received to help address this gap.
5.3.1. Life after Employment
While participants had an image that they would be able to balance their work and personal lives once they were employed, the reality was that the nurses found themselves unable to adapt physically or mentally to the life changes they underwent due to starting their work as nurses. Participants described imagining that they would be working in irregular shifts and be able to physically adapt to shift work, but the reality that nurse participants described finding was one of confusion related to the complexity of the work, its shift scheduling, and how hard the night shift work was on their bodies. These discrepancies can be attributed to the lack of specific information they received prior to employment about work patterns, job descriptions, and the physical strains of the work, as well as the lack of a clear image of the job. Minoura and Takahashi [12] cited the inability to cope with changes in lifestyle patterns and insufficient understanding of the realities of nursing work through clinical practice as reasons that novice nurses quit their jobs. Students who aspire to nursing careers have an opportunity in clinical training to form an image of the nursing work; nevertheless, although they may build an image of the work more easily than other students who do not have access to clinical practice-like education, this remains a mere “image or impression” and does not entail an “understanding of the actual image of the work.” This suggests the importance of students having a concrete understanding of the nursing work and work style before beginning their careers. As such, stakeholders could endeavor to increase opportunities for information provision in order to promote such an understanding in basic nursing education.
5.3.2. Adaptation to Work
In the core category of [Adaptation to work], nurses had an image of gradually learning the work under the guidance of senior nurses, but in reality, they were pressed for time in many tasks. Upon comparing these categories, one may perceive that the images that students described were not inaccurate, but that they also seemed to lack an understanding of the speed with which nurses must deal with their job duties. Unlike when they were students and usually cared for a single patient at a time, nurses found themselves having to deliver care for multiple patients once they got employed, which requires speed. They also described not yet having the capacity of working as fast as they would have liked in order to deliver all the required care, and they perceived this while time was passing by and patients were still in need of care. Indeed, it usually takes a few months for novice nurses to get used to these situations. On the topic of reality shock, Katsuhara et al. [13] argued that it is more practical to view it as inevitable and to seek ways to mitigate it, allow for novice nurses to overcome it, or enhance post-graduate education to deliver more relevant learning on the reality of nursing work. This shows the relevance of devising educational content (e.g., simulations that come closer to the daily reality of nursing work) not only after employment but also in basic nursing education. Among the functions of RJP proposed by Wanous [14] is the vaccine effect, which relieves the disillusionment caused by the reality in an organization. In the case of nursing students, since the clinical training offers a vaccine effect, it is necessary to consider a program in basic nursing education to further enhance the clinical training offered.
In addition, interviewees held the image that they would be able to deliver care with confidence after they were employed. Nonetheless, the reality described by nurse interviewees was not related to such confidence, as reflected in the categories of << Don’t have the time to get involved with my patients the way I’d like >> and << Feeling the weight of responsibility as a nurse >>; particularly, the latter category was related to their descriptions of their perceptions of being incapable of performing their job. Novice nurses do not make use of their time as efficiently as experienced nurses, so they often do not find themselves having the time to talk slowly with patients and have yet to master effective communication techniques. Since these skills require some level of job mastery, providing a space wherein novice nurses have the opportunity to listen to their senior nurses’ stories about their own novice nurse periods and learn about potentially shared experiences could alleviate their impatience and the dilemmas they experience. In addition, it may be useful for students to have more opportunities to take on multiple patients and work night shifts during their field training to gain a more hands-on understanding of the work.
5.3.3. Adaptation to the Workplace
The participants’ image of adaptation to the workplace was one of breaking into a team; however, the only reality they described was that << most people in the workplace are women, but they are easy to work with >>. Thus, the nurse participants in our sample seemingly found no problems regarding human relations in the workplace because they had decided on their place of employment prior to being employed, based on the workplace atmosphere and human relations. They thought that a good workplace atmosphere would lead to a sense of security that would make it easy to ask for help and receive support when facing difficulties at work or other problems. Thus, while student support at educational institutions is important, the workplace culture at the place of employment also has an important impact on job retention.
5.3.4. Career Foundation Building
Participants’ images of their careers immediately before employment included the category of << Orienting one’s career while in the workplace >>. In contrast, the categories from the career realities described by nurse participants included << Not having time to think about my future career >> and << Experiencing depressing days due to not being assigned to the department of choice >>. In many cases, even if they desired to work in a certain area before employment, they were often not assigned to the department of choice. Although it would be optimal if all new nurses could work in the department of their choice, this seems not to be the case in reality; therefore, new nurses could also shift their mindsets, learn to work in the assigned department, and grow as nurses by performing the roles specific to their assigned department. Consequently, it is important to teach students from the beginning of their training that they need to think about how to develop themselves even if they do not work in the department of their choice. Gregg et al. [15] suggested that self-management should be at the foundation of career management and that it needs to be learned and practiced in basic nursing education, including its significance and methods. The present study’s results also suggest that learning about careers in basic nursing education, rather than after employment, is necessary for student nurses to develop the ability to obtain various information and develop their future careers.
5.4. Implications and Strengths
This study’s findings revealed discrepancies between the image that nursing students hold of themselves as employed nurses during the period immediately before their employment and the reality that novice nurses find after employment. The results also demonstrated that it is difficult for nursing students to independently realize the lack of concreteness in the image that they hold of themselves as employed nurses. The study highlights that making nursing students aware of the reality and conditions of nursing work from the initial stages of basic nursing education may promote anticipatory socialization and reduce job turnover after employment because such efforts may allow for establishing and supporting an educational system that enables nursing students to more concretely perceive the reality of the nursing work. In addition, to further concretize nursing students’ image of themselves after employment, it is insufficient for nursing universities and colleges alone to provide basic nursing education. The content of the post-employment image that nursing students described in the interviews in this study was greatly influenced not only by the information and experiences they gained during on-site training but also by the information they obtained when researching employment opportunities. Although the on-site training helped the nursing students get a general idea of the current state of nursing work, there were many aspects they did not see during this on-site training, which were supplemented by hospital information sessions and internships prior to employment. This suggests that it is effective to collect information through both basic nursing education and from the hospital where the student will be employed. This study’s results suggest that by reviewing programs that enable a concrete understanding of the information that has been lacking in both the basic nursing education and the hospitals where student nurses will be employed, nursing students will be able to clarify their image of themselves as working nurses, which will contribute to their socialization after employment. In addition, reducing reality shock for new nurses may make it easier for them to overcome difficulties after employment, reduce turnover rate, and help them become independent as nurses.
6. Limitations of the Study
This study has some limitations. Since the results were based on data obtained from 18 participants recruited from one nursing university and one hospital in a particular region, the results may have been influenced by the educational system and organizational culture of each institution. The nursing students who participated in this study belong to nursing colleges, however, in Japan, there are also nursing vocational schools and nursing junior colleges. Further, the duration of their nursing programs vary and thus, the self-image that nursing students have before employment and just prior to starting their careers may differ. Therefore, there are limitations in generalizing these results to all nursing students. Further analysis is needed to increase the number of targeted universities and facilities and to allow for generalization.
7. Conclusion
The following four categories were extracted regarding the participants’ image of themselves as employed nurses during the period immediately before employment: [Life after employment], [Adaptation to work], [Adaptation to the workplace], and [Career foundation building]. The comparison with the reality that novice nurses faced after employment clarified the lack of concreteness of the images that nursing students held of themselves as employed nurses during the period immediately before employment. This study concludes that allowing nursing students to construct a more concrete image of nurses in employment may reduce reality shock upon entry into the nursing profession, prevent turnover, and enable nursing students to smoothly move toward becoming independent as nurses.
Acknowledgements
We would like to express our sincere gratitude to all research participants for their cooperation with this survey. This research was supported by JSPS KAKENHI (grant number JP18K10222). We would also like to thank Editage (https://www.editage.com/) for English language editing.