A Phenomenological Exploration of Transitional Opportunities Experienced by Intern-Nurses at Labasa Hospital, Fiji

Introduction and Aim: The transition from being a nursing scholar to a practicing nurse is a significant phase in the lives of intern-nurses. During this phase intern-nurses build on experiences which determine their proficiency in future. The transitional experience is a phase of learning, exploration and adaptation for intern-nurses. Transition programs are introduced by healthcare organizations in order to provide intern-nurses with better learning and adapting opportunities. This study aimed to build insight into the opportunities they faced by intern-nurses at Labasa Hospital during transition. Methodology: A qualitative phenomenological approach was used to carry out this study at Labasa Hospital, Fiji. A convenient sample of 22 intern-nurses participated in data collection, through semi-structured in depth interviews. The participants comprised of current intern nurses of Labasa Hospital or those that had completed internship at Labasa Hospital within the past five years and were currently working at different unit at Labasa hospital. The interview data was transcribed verbatim and interpreted using thematic analysis. Results: The demographical findings of this study indicated the ages of the participants to be between 22 and 26 while one participant was 46 years old. Ten of the participants were current intern-nurses of Labasa hospital whilst the remaining 12 had completed their internship less than five years ago and currently working in various units at Labasa Hospital. Thematic analysis of interview transcripts revealed three subthemes which describe opportunities experienced by internnurses; competence, confidence and socializing. The subthemes were further divided into categories. Competence is reflected by categories of skill development and efficient workers while, confidence is defined by communication and dealing with stress. Finally, socializing is categorized by rapport and team building. Conclusion: The findings of this study indicate that the transitional opportunities experienced by intern nurses are confidence, competence and socialization. The opportunities enable the intern-nurses to improve their proficiency level thus improving the clinical outcomes. The findings of this study will help in understanding the transitional experiences of intern-nurses and the need to provide support intern-nurses during transition.


Introduction
The transition phase is a significant time in the lives of nursing graduates as they endeavor to combine their knowledge and gain mastery of clinical skills in a working environment. The transition from being a university student to a registered nurse is being recognized as an issue of interest amongst nursing scholars [1]. The term intern refers to a nurse in the "first stage of their career, recently graduated from university and between the transitional phase of student and qualified nurse". The internship period is a transitional phase for intern-nurses to learn and equip themselves for a demanding career ahead. Intern-nurses' experience of transition at the commencement of a professional career is a process of making substantial adjustment to one's personal and professional life. It consists of nonlinear experiences that move intern-nurses through a range of changes, including; personal, professional, intellectual, emotive, skill, and role relationship changes. The internship program has been designed to expose the intern-nurses to a variety of clinical setting, support their learning, and provide opportunities to assist their adjustment from a student to a registered nurse in a changing clinical environment. During this phase they familiarize themselves in a new setting, develop clinical skills, associate with new co-workers and adapt to new routines. Bjerknes et al. [2] define transition as a process of learning and adjustment that an experiences to attain skills, knowledge and values required to become a successful member of the healthcare team Bjerknes et al. [2]. further state that the process of transition involves shifting from one set of expected positional behaviors to another in a social system; it integrates a social progression in which the intern-nurse adopts the culture and norms of the workplace. This is similar to Duchscher [3], who emphasized that it was the quality of the transitional experience that was likely to influence the intern-nurses' self-confidence and retention in nursing.
The transitional experience determines how the will perform when they become a registered nurse. The internship program is a transitional phase for intern nurses to develop confidence and competence within a supportive environment. Ostini et al. [4] described the transitional phase as a time to move from theory to practical, gaining confidence, moving to new areas, learning new things, taking up learning opportunities and using the time to integrate knowledge into practice. Similarly, Pfaff et al. [5] state that the transition phase provides intern-nurses with opportunities to develop confidence in inter-professional collaboration and adapt to a respectful working environment. Additionally, Coyne et al. [6] transitioning into the workforce provides an opportunity for professional development [6]. Previous literature identifies two significant opportunities for intern-nurses during transition as confidence and competence.
Ortiz [7] defined confidence as the ability to develop in order to provide quality patient care in the complex hospital setting. She also acknowledged that confidence is an essential trait for intern-nurses to develop over time. Similarly, Pfaff et al. [5] defined confidence in the context of nursing as a secret that can be confided or entrusted to another, the belief in oneself and ones' abilities as well as freedom from doubt and professional confidence described as an internal feeling of self-assurance and comfort, and being tested and/or reaffirmed by other nurses, patients and friends. All three types of confidence are equally important in the nursing profession. Nurses need to elicit trust in order for patients to confide in them, to believe in one self in order to perform ones' duties to the best of one's abilities and have confidence enabling self-assurance throughout one's career.
According Ivey [8] stated that the transitional phase increases the level of confidence in intern-nurses. Evans et al. [9] stated that confidence usually develop when the intern-nurses rotate though new allocation areas, relearning the specialized skills and learning to cope this the work loads of different units. Ulrich et al. [10] concluded that self-confidence of intern-nurses grew over time. Similarly, Coyne et al. [6] stated that intern-nurses gain confidence about their work and sense greater accountability towards tasks delegated to them. Coyne et al. [6] also stated that during the transition phase intern-nurses gain confidence in providing care as they have learnt more about medications, understood routines, adapt to emergency situations and build communication with colleagues and the families of clients. Shipman [11] states that once an intern-nurse is able to differentiate between what is real and what is ideal, that is experienced and what is learnt in school, the level of confidence increases and the nurse is able to increase the level of competency.
The second opportunity for intern-nurses is to develop competency in nursing procedures. The Australian Nursing and Midwifery Council (ANMC) [12] defines competency as the combination of skills, knowledge, attitudes, values and abilities that strengthen performance in a profession. Hoon [13] stated that nursing competency is a vital concept in nursing and there is no clear way to define it due to the complexity and multifaceted nature of nursing practice itself. Hoon [13] also discussed the four stages of conscious competence theory to elaborate on a clearer picture of the learning process in becoming a competent nurse. The four stages of conscious competency theory are unconscious incompetence -when the person is unaware of what to be done, once the person acquires the importance developing of a particular skill, the person can proceed to the next stage of conscious incompetence whereby the person is aware of the unknown skill and will spend some time learning the skill, followed by the next stage of conscious competence which is when the individual knows how to apply the skill. The last stage is unconscious competence when the skill becomes a second nature to the person and the skill can be applied without thinking, thus becoming a competent practitioner. According to Coyne et al. [6] the transition from an intern-nurse to a competent practitioner is a complex experience which builds their competency levels, establishing reliability and creating a positive attitude towards the clients. According to Hezaveh et al. [1] competency is one of the most significant requirements for working in clinical environment and lack of competency can be very stressful to an intern-nurse. Nurses are expected to be competent in so many ways; communication skills, administration of medications, intravenous therapy, wound management and infection control amongst many other things. Ulrich et al. [10] stated that intern-nurses develop competency gradually as they progress into their residency. A study conducted by Karahan et al. [14] tested the pre and post competency of intern-nurses. At the commencement of their residency the nurses rated themselves incompletely competent in the 205 competencies tested while at the end of their residency the same nurses rated themselves as having a moderate to high level of competency. Hofler et al. [15] state that effective mentorship during the residential period increase the competency level of nurses transitioning into the workforce. Karahan et al. [14] also stated that the intern-nurses developing competency in nursing skills improve the quality of care they provide.
Donilon [16] concluded that professional competence is essential in nursing practice in order to ensure that safe patient care is carried out despite competency being a complex myriad of knowledge and skills within a nurse's scope of practice. Similarly, Kim et al. [17] established that nursing competency is enhanced through the transition process which provides intern-nurses with the opportunity to gain the nursing knowledge, skills, and attitudes necessary for carrying out quality and safe patient care. Karahan et al. [14] stated that newly trained nurses perceive themselves to be insufficiently prepared for full time work but through transitional experiences they are able to gain competency and adequate know-how to survive the nursing work culture. According to Karahan et al. [14] intern-nurses perceive themselves to be insufficiently prepared for full time work but through transitional experiences they are able to adapt to the healthcare workforce. Thomas et al. [18] elaborated that the transition process is instrumental in assisting intern-nurses in development of knowledge and skills thus becoming confident and competent nurses. Despite the transitional experiences being an important aspect of the development of internnurses, there are no existing literatures on the transitional opportunities available for intern-nurses in Fiji. This study aimed to explore the opportunities experienced by intern-nurses during transition at Labasa Hospital, Fiji.

Methodology
A phenomenological qualitative approach was used to explore the transitional experiences of intern-nurses at Labasa Hospital. According to phenomenological research studies human experiences through the descriptions provided by the individuals involved. It is a research design that has been widely used in healthcare to study areas pertaining to investigating experiences in real-world settings [6]. Participants in this study consisted of a convenient sample of 22 new graduate nurses who were employed as an intern at Labasa Hospital for more than six months or had completed an internship at Labasa hospital in the last five years. Their participation was voluntary.
Recruitment of participants was carried out by identifying potential participants through conversation with the Human resource manager. They were approached by the research assistant and given a verbal explanation and a participant information sheet outlining the purpose of the study and the timeframes of the interview. Upon agreeing to participate, each participant was asked to sign a written consent prior to the interview. Data was collected through semi-structured in-depth interviews by a research assistant. Each interview lasted between 40 to 60 minutes. All interviews were audio recorded while unstructured note were taken as well. All interview audio recordings were transcribed verbatim by the principal researcher. Following which a review of transcriptions was carried out to correct errors and to remove references to names, places and significant events to ensure anonymity for the participants. Once the transcriptions were clarified, data analysis was carried out.
Thematic analysis was the choice for data analysis in this study. It was carried out using four steps identified by Green et al. [19]; immersion in the data, coding, creating categories and the identification of themes and subthemes. The principle researcher read and reread each transcript line by line, identifying similar phrases and words than assigned numbers to that word or concept. The coded data that had similar characteristics were grouped together. Once grouping of similar data was completed, descriptive themes were identified to reflect the lived experiences described by the participants.
Ethical approval for this study was obtained from Fiji National University (FNU) College Health Research Ethics Committee (CHREC) and Fiji National Health Research Ethics Committee (FNHREC). Permission was obtained from the Medical Superintendent of Labasa Hospital prior to the commencement of the interviews.

Results
A total of 22 participants took part in data collection through indepth interviews. Out of the 22, 10 were currently working as internnurses at Labasa Hospital while the remaining 12 had completed their internship less than five years ago and currently working in various units at Labasa Hospital. All the participants were between the ages of 22-26, only one participant was 42 years old. Majority of the participants were females (nineteen) while three were males. Thematic analysis of the interview transcripts identified subthemes that describe the opportunities experienced by intern nurses during transition. The three subthemes identified were: competence, confidence and socializing. These subthemes were further categorized to reflect on the findings of this study. Stated below are reflections on competence.

Competence
All of the participants (n=22) mentioned that competency in nursing skills is developed during internship rotation. The participants described their competency as either skill development or gaining efficiency.
Skill development: P18 (a 24 years old female) described how she developed her skill level through her attachment in labour ward and working independently: "At the beginning of my nursing career I felt I could never do deliveries, after my attachment in labour ward, doing deliveries on my own a number of times, I have learned the skill" P21 (a 24 years old male nurse) stated that he was able to become competent in nursing procedures after the transition phase: "As a student I learnt the procedures. I really mastered the skill after my internship" Becoming efficient workers: Majority of the participants stated that they not only developed skills during internship but became efficient in the procedures by repeatedly doing the procedure. P2 (a 32 years female nurse) described that repeatedly doing a procedure makes it easy and efficacy is built: "By doing procedure over and over again, it becomes easy, like doing admissions, every rotation requires you to admit patients and draw their care plans, and after doing it so many times it becomes easy" Similarly, P13 (a 24 years old female nurse) voiced that rotation is vital in building efficacy as well as contributing towards gaining experience: "During rotation I gained experience and became efficient in nursing procedures"

Confidence
Many of the participants indicated that their confidence level increased as they progressed through internship. They were able to build confidence to deal with stressful situations and also address issues dealing with the clients. One of the areas where the participants stated that they gained confidence was communication.
Communication: P5 (a 25 years old female) indicated that she felt more confident in referring cases: "I wasn't confident in referring cases to the doctor but now I can do that confidently as I have learnt how to explain, moreover now I know what to say" P11 (a 24 years old female nurse) described how she was able to learn more about medications during her rotation and gained confidence to speak about it: "When I started off I was very nervous to talk about medications, through the rotations in different wards, I have learnt all the medications, now I talk about medications confidently" P14 (a 26 years old female nurse) felt that she has gained confidence to talk about the conditions people have: "I am more confident talking to patients about their problems now, before I felt I didn't feel very confident talking to them" Dealing with stressful situations: Nurses deal with stressful situations in their nursing career. This can be in the form of acute emergencies, delivering regular nursing care and dealing with difficult clients and colleagues. Majority of the participants felt that the transitional experienced has moulded them to deal with stressful situations. P7 (a 23 years old nurse) stated that she has gained more confidence to deal with stressful situations: "Now I can deal with stressful situations. I am more confident now than I as at the beginning of my career" P5 (a 42 years old female nurse) described how a situation she faced boosts her morale and made her confident: "I was in the Gynae ward, when one of my patients wouldn't stop bleeding, I suggested to the senior staff that the patient may be having ectopic pregnancy, she called the doctor. Later the patient was taken to OT. I felt so confident about the knowledge I have" P13 (a 24 years old female nurse) indicated that internship rotations enabled her to let go of her insecurities and her level of confidence increased Socializing Some of participants indicated that they were able to build a working relationship with fellow nurses and other healthcare workers. Socializing has been categorized as building rapport and team building.
Building rapport: Most of the participants feel that internship has given them an opportunity to meet and make friends with other people working at Labasa Hospital. P6 (a 22 years old female nurse) indicated that during transition intern-nurses get to know many different people: "You work with different groups of people, not only nurses but people from different departments and cadres" P11 (a 24 years old female nurse) stated that through internship rotation she has come to know all the nurses of the hospital: "Moving from one ward to another, I met so many nurses, by now I think I know all the nurses in the hospital and they know me" P15 (a 25 years old female) expressed that she was able to develop friendship during rotation: "I made so many new friends during my internship" Similarly, P19 (a 24 years old female nurse) described that internship rotation allowed her to intermingle with many people: "I got opportunity to interact with so many people" Team building: Some off the participants have indicated that teamwork has helped them to learn better and build lasting relationships with their colleagues. P15 (a 25 years old female nurse) how making friends with intern doctors helped her to learn new things: "I was able to make good friends with intern doctors. They helped me a lot especially if I didn't know something" P21 (a 26 years old female nurse) stated that developing rapport makes working easier: "As a member of the team, you make rapport with others in the team, it makes working together easier" The results of this study reflect the positive experience of internnurses of Labasa Hospital which made their transition into their professional role a constructive phase. Further elaboration of the results is provided in the next chapter.

Discussion
The opportunities provide the intern-nurses with a better chance of learning and working with other people be it colleagues from the same or different cadre. The results of this study provide a reflection on the opportunities experienced by the intern-nurses working at Labasa Hospital.The opportunities identified are competence, confidence and socializing. Lima et al. [20] states that competency is of utmost importance in any healthcare setting. The outcomes of this study is similar to Coyne et al. [6] which states that intern-nurses gain a new level of competency through transition. According to Ulrich et al. [10] the self-confidence are enhanced though transition. Similar outcomes were observed in this study whereby the participants identified skill development and becoming efficient workers as two categories of competence. The participants indicated that as they rotate in different wards they are able to achieve a higher level of competency in comparison with what they started their career with. Through repeatedly doing the same procedure they are able to become efficient workers. Theisen et al. [21] and Rush et al. [22] state that competency levels of intern-nurses develop through well-developed orientation programs. This is reaffirmed by the participants of this study who indicated that their competency level increased during their internship rotation.
According to Ostini et al. [4] intern-nurses need to be supported throughout their rotation in order to reach a desired competency level. Their study also emphasized that a learning environment needs to be created for the intern-nurses to continuously feel supported and continue learning during internship. Goodwin [23] states that by closing the learning gaps of intern-nurses, a new competency level can be achieved which will have a positive impact on the quality of patient care provided. According to the guiding principles of American Organization of Nurse executives (AONE) [24] the healthcare environment demands nurses not to be only competent but confident as well. This was reaffirmed by the findings' I this study.
Shipman [11] defines confidence as belief in oneself, in one's judgment, psychomotor skills, knowledge and the ability to draw conclusions from it. Intern-nurses in this study expressed gaining confidence though the transition which is consistent with reviewed literature. Coyne et al. [6] concluded that intern-nurses gain confidence in nursing procedures as they become more knowledgeable and skillful during transition. Furthermore, Evans et al. [9] state that the internship year gives intern-nurses an opportunity to adapt to the role and develop confidence to perform the responsibilities of the role. All the above mentioned statements are reaffirmed by the findings of this study which indicates that intern-nurses gain confidence through transition. The outcomes of this study point out that as the internnurses rotate through various wards there is a boost in their morale and their confidence level is lifted resulting in better communication with the colleagues and clients. The participants also stated that their approach to stressful situation has improved through transition as they are able to better deal with demanding situations with more confidence, leading them to work independently. This outcome reinforces the findings of Missen et al. [25] which states that after a year of work the intern-nurses are confident to work independently. Once the intern-nurses gain confidence they are able to familiarize themselves with the new working environment and interact with people which leads us to our next subtheme socializing.
Socializing in the context of this study means establishing a working relationship with colleagues and clients. The findings of this study supports McKenna [26] which states that during the internship year intern-nurses feel a sense of belonging and are able to complete their socialization into a clinical area. The two categories that describe socializing as identified by the participants are establishing rapport and team building. Through rotation into various wards intern-nurses are able to establish a rapport with the multidisciplinary team in the ward and communicate with the clients effectively. The findings of this study indicate socialization as a contributing factor towards initiating teamwork. The intern-nurses feel that they belong to a multidisciplinary team and are able to contribute to the care of the clients. The findings of this study supports Pfaff et al. [5] which states that intern-nurse gain interdisciplinary collaboration through transition which enables them to contribute provide better nursing care. According to Moore et al. that transitional programs are essential in building multidisciplinary teams in order to improve nursing care.

Conclusion
Results of the overall study have shown that intern-nurses perceive higher levels of competency and confidence over time. Accommodating a smooth transitional experience for the internnurses would be the most beneficial to the organization as improved competency would lead to high quality patient care, achieving cost effectiveness and most importantly improved patient outcomes.
Internship year provides the intern-nurses with the opportunity to gain knowledge, kills and attitudes necessary for carrying out quality and safe patient care. In conclusion, the study findings provide important information about the success of the internship rotation that facilitates the transition of intern-nurses from educational learning to being a registered nurse. The information obtained through this study will enable the management and nursing leaders of labasa Hospital to facilitate a positive transitional experience which will enable internnurses to become knowledgeable and proficient nurses of the future.