Constructing Nursing Professional Identity in Impossible Situations: A Longitudinal Narrative Study of New Nurses’ Transition to Practice

Population and Recruitment

We sought nurse baccalaureate graduates from a single U.S. state, restricting recruitment to those who had passed their licensing exam within the previous few weeks, accepted medical or surgical nursing positions in an acute care, not-for-profit hospital, and consented to participate in a sequence of interviews conducted over multiple months. We specifically focused on hospitals offering formal residency and preceptorship programs – structured orientation programs, usually lasting several months, that incorporate a variety of mentoring, supervision, and individualized support interventions for new hires. Intended to address some of the transition failures of the past (Hampton et al., 2021), programs of this type have been implemented across the globe over the past decade and have been associated with increased retention and satisfaction among first-year nurses (Eckerson, 2018). Recruitment flyers were sent to student nurse organizations and deans of regional nursing schools, who were invited to share study information with their respective contact networks.

Data Collection

Interviews were conducted at two time points. The first took place right after the nurses were newly licensed and had accepted their first jobs but had not yet started working. The second was conducted about 4 months later, after they had finished their precepted orientation. Consent was reviewed with each interviewee during recruitment and then again prior to each interview. Interviews were conducted via online teleconferencing and recorded by the lead investigator. Interviewees were assigned pseudonyms, and transcripts were de-identified and assigned numeric codes in preparation for analysis.

Interviews conducted within a narrative framework involve open-ended questions that invite storytelling, allowing participants to recount experiences in their own way (Mishler, 1995). The initial round of interviews began with the prompt “Please tell me what you envision for yourself as you begin your nursing journey.” The second round began with the prompt “How is it going?” Broad opening questions were followed by probes that elicited examples of situations or encounters the nurses regarded as particularly important or impactful. Participants received a $50 USD Amazon gift card following the first interview and a $75 USD gift card following the second interview, as per a protocol designed to encourage longitudinal study retention. Ethical approval was obtained from the Rutgers University Institutional Review Board [Pro2025000080].

Data Analysis

Transcripts were read and analyzed by two researchers. The primary investigator is a seasoned nurse executive with more than 20 years of experience in recruitment, supervision, and hospital administration. The second investigator is a senior nurse-ethnographer. Both authors manually annotated transcripts following each interview. Drawing from Riessman’s (2008) three-part method, we first identified basic content and themes. We then extracted stories exemplifying each theme, noting recurring narrative features or structures in how the stories were told. After that, we marked moments in each story when interviewees made judgments or used evaluative language, discursively positioning themselves in relation to what was being described.

Annotation was recursive and iterative. For both interview rounds, emerging conceptualizations were developed, elaborated, and refined in light of each subsequent interview. To keep narratives intact and develop themes longitudinally from the first round of interviews to the second, we organized layers of annotation into extended spreadsheets for each interviewee. This provided a means to engage dialogically over time as we compared and commented on each other’s reflections and emerging ideas. Following the model of Maben et al. (2007), we then selected a small subset of exemplar stories that vividly illustrated the themes and longitudinal trends we found most salient and reflective of the group as a whole. This paper focuses on data related to one theme in particular – the disjuncture between what new nurses hoped for themselves and what they encountered in actual practice.

Patterns Reported Across the Settings

A description of basic content patterns in the data is presented below, followed by a more in-depth interpretive examination of nurses’ stories and their longitudinal development. In the first round of interviews, before starting their jobs, the interviewees focused mostly on their school clinical rotation experiences, the job-seeking process, and their excitement for what was to come. Seven of the 10 said they originally sought positions in specialty areas such as the emergency department, maternal-child health, or pediatrics, but had found openings only in medical-surgical units. Six had been interviewed exclusively online and had never seen or visited the units where they would eventually be assigned. Seven said that even during nursing school, they had been encouraged by families and teachers to perceive bedside nursing as a “stepping-stone” to higher-level educational credentials, positions in advanced practice, or better-paying jobs like travel nursing. Most described having clinical preceptors during nursing school who were supportive, helpful, and enthusiastic about teaching. All of them also described having preceptors who signaled clearly – sometimes very directly – that they did not want to work with students, felt burdened by the extra workload of supervising students, and had been forced into the role.

In the second round of interviews, the nurses focused mostly on their hospital orientation programs, encounters with preceptors, and the first days or weeks of independent practice. Three reported that their orientation period had ended earlier than planned due to staffing shortages. Six said they had been assigned preceptors with fewer than 2 years of nursing experience. Six reported multiple episodes of turnover and reassignment in preceptors rather than long-term mentoring relationships with any single individual and observed high variability among preceptors in fidelity to formal care protocols. One had been assigned a travel nurse as a preceptor because seasoned staff nurses were in short supply in her facility. Six of the interviewees said that a majority of the nurses working alongside them were “my generation” or “around my age,” which they perceived as fostering a sense of belonging and congeniality. All spoke with awe and pride about the clinical complexity of nursing, the remarkable variety and diversity of patients and of people in general, and the vastness of information that needed to be mastered. Four also described situations in which they were kicked, punched, or slapped, in all cases by fragile or medically vulnerable elderly patients diagnosed with dementia, altered mental status, or psychiatric illness. Every interviewee observed that the combination of older patients’ acuity, vulnerability, and aggression posed challenges they did not expect and did not know how to manage. Seven also described patients, families, or other healthcare providers who yelled at them or insulted them.

Stories of Disjunction

The most prominent thematic feature of stories told in the first interview was the disjunction between new graduates’ idealized expectations and the realities of practice. As noted previously, aligned with well-established patterns in the literature on the transition to practice, this theme was further strengthened in the second round of interviews, as all the new graduates shared multiple stories of interactions they found surprising and disturbing. However, instead of functioning as mere chronological accounts of events, their descriptions of disjunction served as reference points, rhetorical moments from which to offer contrasting images of what the interviewees wanted for themselves as nurses. The stories shared a common narrative structure – beginning with a summary “encapsulation” (Labov & Waletzky, 1967), followed by characterization of the situation as a moral challenge or dilemma, and then by a description of what the interviewee felt, did, planned, or hoped to do in response. In the examples presented below and in many other similarly structured stories, the nurses conveyed a paradox – a strong sense of pride and accomplishment, but also profound disappointment. Even while marveling at their new clinical skills, the nurses all portrayed institutional practices, processes, and cultures that made it impossible to fully enact the values they wanted to associate with nursing.

Danielle: Finding Sense of Competence as Working Conditions Become Unpredictable

In the first interview, Danielle felt that she lacked confidence and was intimidated by the idea of interacting professionally with preceptors and patients. Once working, she began her orientation on the day shift. At first, she said, she was struck by the number of nurses who did not conduct complete physical assessments of patients, sometimes charting by copying what was entered on the previous shift.

I just remember thinking, why was no nurse assessing the patients? I mean, I would see the nurses have their stethoscopes on, but when I was with my preceptor, she never used it. Even towards the end of the first 4 weeks, I didn’t see a lot of people using their stethoscope. . .I was like, why is there no assessment being done?

After transitioning to her assigned unit, however, Danielle became much more confident, and her storytelling focused on her personal accomplishments as a night-shift nurse. She expressed a great deal of pride in the clinical skills she had acquired and referred to herself as a nurse who likes to “get things done.” Despite pride in her newfound and expanding skill set, however, Danielle said she planned to leave at the end of the year to pursue a position at an aesthetics-and-wellness spa. She had already visited a spa as part of an informational tour for prospective staff. A long-term commitment to hospital nursing, she said, seemed “not feasible.”

A few weeks after she started the job, she explained, the hospital had announced budget cuts, including a one-third reduction in night-shift staffing. This increased nurse-patient load on Danielle’s shift and reduced opportunities for breaks and meals. Danielle also noted that a hospital-wide rapid response team was available for emergencies, but night-shift clinical support had been reconfigured and was now limited to a remote on-call nurse practitioner who provided phone consultation only for routine care. Danielle contracted both COVID-19 and influenza within the first 3 months of work, which she attributed to hurrying in and out of isolation rooms. She had finally encountered a preceptor she described as having “higher standards” than those she met in the first days of orientation, but the preceptor assigned to her was about her own age and had been practicing as a nurse for only about 8 months, which qualified her as “experienced” by the unit’s norms.

Danielle’s story presented a young person’s effort to narrate a sense of herself as a competent nurse while observing the supporting infrastructure of care progressively withdrawn from the environment around her.

Gianna: Seeking Honest Dialogue Under Conditions of Individualized Blame

In the first interview, Gianna expressed concern about feeling “new and alone” in her first nursing job. During the second interview, by contrast, she talked fondly about other new-graduate nurses on her unit and about gaining proficiency in clinical skills under the guidance of attentive preceptors. She also told a story that deeply disturbed her about a colleague from her orientation cohort. On her friend’s first day after finishing orientation, the unit was particularly busy with high-acuity patients. More seasoned staff were unavailable, so the new nurse was assigned to handle the admission of a medically complex elderly patient. When she questioned the appropriateness of assigning this kind of patient to someone working without a preceptor for the very first time, the charge nurse assured her “he should be okay.” Soon after the shift started, however, Gianna heard a commotion and ran down the hall, finding the patient on the floor in a pool of blood in his room. Gianna called a code and initiated resuscitation. Eventually, the patient was transferred to intensive care.

For several weeks afterward, Gianna said, conversation focused on her friend, who had been returned to orientation “for more training.” Gianna marveled that unit managers repeatedly advanced a narrative in which the new nurse was to “blame” for the incident because she had forgotten to activate a bed alarm. Gianna worried that the story oversimplified a complex, multifaceted situation – placing responsibility on one person and offering individual corrective action in clinical skills when the incident involved broader organizational problems of crowding, timing, staffing, and interdepartmental communication. She also noted that investigators had discovered her friend’s orientation checklist had been filed without being completed. Moreover, neither she nor her friend had met with the nurse educator on the supposedly mandatory schedule. Concerned that her friend was being shamed, she checked in:

She said she’s okay. Then she said, like. . .going back on orientation is, like, she feels like. . .not a failure, but like, you know, like, she’s just reminded of what happened. . .And ever since then, also, there’s always really, like, a big emphasis, like, bed alarms, bed alarms, and, like, fall risk. And every time they mention that. . .she feels. . .that they’re talking about her specifically.

Gianna also described how she, too, was “blamed” for a complicated situation during her own first week off orientation. An elderly patient with altered mental status had been assigned a sitter from the hospital float pool. The sitter insisted that the patient was becoming aggressive and needed medication, but when Gianna called the physician, the patient was calm. The sitter then called the staffing office to complain about Gianna, and when the patient smeared feces, the sitter walked out of the unit, leaving Gianna stuck alone at the patient’s bedside. Gianna felt, again, that a new nurse was being held individually responsible for a complex, multifactorial turn of events.

Overall, Gianna was confident about her skills, enjoying her coworkers and the clinical challenges she faced, and eager to keep learning. But she also noted that nurses often seemed to be placed “in the middle,” subjected to pressures both from above and from below, without any means to seriously or honestly discuss the multiple complex organizational-level factors leading to adverse events. Gianna’s story presented a young person’s effort to make moral sense of discursive norms that foreclosed honest, serious analytic reflection and communication about complex situations, reframing institutional problems as matters of individual blame or technical gaps in nurse training.

Irene: Trying to Feel Conscientious Despite Labor Practices Devaluing Nursing

In her first interview, Irene referred to herself as “shy” and looked forward to learning how to feel more confident and comfortable in her social interactions with others. In the second interview, she reported that with staffing “low” in her unit, she had been taken off orientation a week before the planned end date. By this time, however, she felt ready, and she was happy about the chance to practice independently sooner than expected. She described her unit as having an atmosphere of camaraderie, noting that she found it comforting to work in a setting with a high proportion of Filipino nurses like herself. She emphasized pride in her evolving skills and said it had brought her great pleasure to learn that she had the ability to build trusting, caring, compassionate relationships with patients.

But Irene also told a story about organizational protocols that could not be accomplished in the allotted time frame. The shift officially began at 7 pm, she said, and the shift report usually required at least 30 min. However, the hospital had a policy requiring Braden and fall risk assessments and documentation be completed for all patients by 8 pm. To meet this demand, Irene said, all the night nurses arrived at work 30 min early, giving them extra time to review the electronic medical records, and had developed what Irene called “rituals” – personal strategies for preparing in advance of the shift. Irene, for example, collected a box each day and arranged her supplies in it before clocking in. As hospital policy prohibited any staff from signing in before 6:54 pm, this preparatory work was unpaid, effectively extending the 12.5-hr shift to at least 13 hr.

Emphasizing that while she was enjoying her peers and her patients, Irene also said she was now “open to a different position” away from the bedside. “Now I understand why nobody wants to do bedside. . .,” she said. “I can’t break myself in two and attend to everybody.” Irene’s story presented a young person’s attempts to define herself as a conscientious, compassionate nurse in the context of labor practices which devalued nurses’ good will and hard work.

Ellen: Seeking a Sense of Moral Community Where Collaboration Is Not Universally Evident

In the first interview, Ellen described a sense of community in nursing school and looked forward to finding the same in her new job. In the second interview, she told a story about dropping a narcotic pill on the floor of the medication room. Ellen knew it would be easy to retrieve the pill and give it. But she also felt obliged to do “the right thing,” as she put it, even though this involved calling another nurse to witness the medication being wasted. Ellen prided herself on this choice, noting that “it was a lot of anxiety. . . .[but] like, you have to correct that mistake. . . .to be open about making mistakes, which is very important to do.”

Ellen also reported confidence and optimism about how much she was learning. She was awed by the skill and finesse of the more experienced nurses and excited that someday she, too, might be able to achieve their seemingly natural, instinctive ability to solve clinical challenges. She noted, however, that nurses on her shift faced what appeared to be a persistent lack of reliable support from anyone outside the unit and shift. As an example, she told a story about a highly combative and confused elderly patient admitted with his nose bleeding profusely. As he kicked and thrashed, five nurses worked together to try to calm and restrain him to address the bleeding. As he continued to deteriorate, losing blood and becoming increasingly confused, Ellen was assigned to call the night-shift Nurse Practitioner (NP). When the NP arrived, he remained at the nursing station, talking on the phone about an issue elsewhere in the hospital. Ellen described repeatedly approaching, but each time, he acted as if he didn’t see her. Finally hanging up the phone, he called out to the staff to say his shift was over. While walking out, he announced sarcastically to the blood-drenched nurses and still-thrashing patient, “You guys have a great night.”

Ellen noted that it wasn’t the first time a clinician in a position of authority had opted out of supporting nurses on her shift, leaving the nurses to manage problems on their own. She talked about struggling to make sense of what seemed to her a betrayal and overt act of humiliation by someone who was supposed to be a fellow nurse.

I was just surprised because he’s a Nurse Practitioner, so he was at the bedside at one point. So I was just surprised, like, what. . . like, you would understand more than, like, the doctors would on what we’re going through.

Ellen’s story presented a young person hoping to envision herself as a member of a moral community but finding an institution not governed by a shared sense of community and moral obligation.

Abigail: Seeking Authentic Communication but Finding That Forthrightness Is Elusive

During her first interview, Abigail described her school clinical rotation in a hospital where the nursing staff “were very good at. . .the rapid assessments and. . .medication administration. . .[but] didn’t really have time to like, really get to know the patients and care for the patients as a whole.” She characterized their work as “kind of just like clockwork” and observed that the staff appeared to have unspoken agreements to avoid interacting with certain patients. She told a story about an elderly man who screamed for several hours about discomfort and pain.

This one particular instance. . .kinda really impacted me negatively. There was this old man. . . .really anxious the entire time. . .and he was like begging people to talk to him. . .he wasn’t tolerating the nasal cannula but. . .was just like begging people to help him. He was like, help me, for hours and hours, and. . .I just felt so terrible because everyone was just ignoring him.

The situation led Abigail to think of her own grandfather, “. . .’cause I feel like if that was my grandpa, I would be very like upset that no, like everyone was just ignoring him, and he was like, really anxious and in pain.” She speculated how the nurses could have responded differently, perhaps discussing ways to address his needs:

Maybe, instead of just like ignoring him, they could. . .you know, be like. . .just take his mind off of the burning sensation. Just like talk about something else, or like guide his if like. . .use guided imagery. . .I don’t know.

Abigail took no action herself, however, noting that “I want to be a good nurse,” but “the hospital’s kind of just like, the environment forces you to do like such things.” She said she hoped eventually to be able to do things differently – “to get to know my patients a little better, and, you know, like, take care of them.”

In the second interview, Abigail told yet another story about problems left unspoken. She and her preceptor were administering injectable medications in a patient’s room. The preceptor drew up double the prescribed dose. When Abigail observed an error about to occur, she repeated the dose aloud, subtly trying to alert the preceptor without alarming the patient. The preceptor then corrected the dose. Abigail spoke of her pride and sense of accomplishment in preventing a mistake without frightening the patient. But she also described how her preceptor said nothing. The incident was never acknowledged or mentioned afterward, as the preceptor “just pretended that she was going to get rid of 0.25 more” and reacted as if nothing happened. Abigail suggested that if she were a preceptor, she would have used the opportunity to model openness and praise the new nurse’s timely action. Even more, Abigail struggled to understand why a near miss would not be discussed in a more forthright way. Abigail’s story presented a young person who connects nursing to authenticity and relationship-building but encountered an institution where unspoken taboos discouraged forthright conversations about error.

Fiona: Championing the Underdog Under Conditions of Invisibility

In the first interview, Fiona told a story about an interaction between a patient and a nurse preceptor. Although the unit was not particularly busy at the time, her Spanish-speaking preceptor repeatedly addressed the patient in Spanish despite clear indications that the patient, a Portuguese speaker, did not understand what was being said. Fiona, herself a Spanish speaker, perceived that the preceptor was intentionally disregarding the patient’s clear expressions of confusion and distress.

I’m like, the patient doesn’t speak Spanish. The patient speaks Portuguese. And he’s telling you, ‘I don’t know what you’re saying.’ So why are you talking to him in Spanish?

Fiona described how the preceptor repeatedly pretended not to hear her as she tried to encourage him to call for a translator. At first, since she was still a student, Fiona hesitated to take action. But after several minutes, she decided to defy the preceptor. She called the translator, describing this as a transitional moment “when I really started to feel more like a nurse. . .”

When I. . .got the translator out on my own. . .that was where I was kind of like, I hope I’m not disrespecting this nurse right now, but I’m like, the patient’s gonna come before your feelings, I’m sorry. So. . .yeah, and I was making decisions. . .I wasn’t just following what [the preceptor] was doing. I was making an active decision for the patient, and then I was like, whoa. . .this feels a little bit better. . .

In the second interview, Fiona told a story about being assigned to shadow a patient care technician as part of her initial unit orientation. She described feeling shocked by the physical and emotional demands of this job – issues conspicuously absent from nursing school classes where the focus was on delegation and supervision rather than understanding work processes in an organization as a whole. Fiona said the experience sensitized her to perspectives she never considered. Vowing to show empathy to coworkers of all ranks, she said, she now realized that nurses are far from alone in feeling undervalued and overextended. “That has to be the hardest job in the hospital. . .that was kind of my introduction to the floor, and that was rough. I cried multiple times.” Fiona’s story presented a young person who wants to think of herself as an advocate for the underdog but finds tacit norms of invisibility in which the needs of patients, like the contributions of lower-status workers, can remain unacknowledged.

Implications

In the early 1970s, Patricia Benner (1974) described a series of experimental “seminars” that provided new graduates with a forum for frank discussion of troubling experiences. More recently, Mbuthia et al. (2021) have described the need for “formative spaces” where new nurses can speak openly about their struggles. There may be value in reviving these concepts, as our study suggests that new nurses need venues for difficult, courageous conversations about the moral challenges they experience. Reviving this idea in connection with transition-to-practice programs may be a practical, scalable strategy for enabling nurses to engage in the kind of “identity reconciliation work” (Mbuthia et al., 2021, p. 5) necessary to process tensions between ideals and workplace realities. Leadership development for preceptors and managers to adequately support novice nurses in difficult conversations, as well as the impact of such programs, could be an important area for potential future research.

However, the findings of this study also suggest a need to address conditions beyond training and orientation. Even the best-developed opportunities for dialogue and reflection cannot be sufficient without corresponding organizational change. By openly acknowledging and taking steps to halt current trends in workload, staffing, documentation burden, and the normalization of fiscal policies that can undermine bedside caring, organizations may begin to ameliorate some of the conditions currently disincentivizing new nurses from remaining in bedside practice. In a recently published book on nurse retention, Kristoffersen (2026) argued that nurses need workplaces which enable them to fulfill “horizons of identity” (p. 213) – to enact their moral commitments in practice by caring both for patients and for themselves. Providing empirical evidence of the link between practice conditions and nurses’ sense of self at the very start of their professional lives, our findings affirm this concept.

Without structural changes that promote dignity and enable care, the “leaky bucket” effect (Porter-O’Grady, 2026) is likely to persist, reflecting system failure rather than individual inadequacy. Retention will depend not on additional technical skills training or extended orientation, but on reforms that allow nurses to practice in ways consistent with their professional ideals. If we want nurses to stay, we need to give them environments worth staying for.