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

Abstract

Newly graduated nurses are expected to develop a strong professional identity during transition to practice, yet considerable research describes a gap between the ideals taught in nursing school and the realities of clinical work. Mounting evidence suggests that the transition to practice has become more complex in recent years, despite the widespread implementation of precepted orientation programs. Using a narrative analysis approach, this longitudinal qualitative study examined 4 months of the transition to work among 10 newly licensed nurses who accepted positions in medical-surgical units across 5 hospitals in a single U.S. state. In stories they told about hospital life, the nurses rhetorically presented themselves as they believed nurses should be seen, but also conveyed profound disappointment with institutions that constrained their ability to enact values they ascribed to nursing, such as honesty, collaboration, forthright communication, and serious analytic engagement with complex problems. Portraying healthcare institutions as places that render these aspects of nursing impossible, their narratives illuminate how contemporary practice conditions frame processes of identity construction. Our findings enrich understanding of contemporary retention trends and offer a window into the concerns of an emerging generation of nurses.

Introduction

It is often said that newly graduated nurses need to build a sense of professional identity during their first years following licensure (Kaldal et al., 2023). Yet multiple authors have documented profound gaps between the professional ideals nurses are taught to espouse in nursing school and the realities they encounter when they begin working. Half a century ago, Kramer referred to the initial stages of school-to-work transition as “reality shock” (Kramer, 1974), and Melia (1987) detailed conflicts between nursing’s self-proclaimed emphasis on empathy and holism and the myriad pressures new nurses experience that incentivize speed and task orientation over more person-centered approaches. Using the term “transition shock,” Duchscher et al. (2009) noted that new nurses are often overwhelmed by their workload and lack of support from more seasoned coworkers. Curtis et al. (2012), Mackintosh (2006), and Maben et al. (2007) all described internal conflicts among idealistic young nurses entering workplaces characterized by cynicism among senior staff and intense pressure to work quickly and conform to group norms. All emphasized the role of such early-career disjuncture in high attrition and job turnover rates.

Today, emerging research suggests that the transition to practice has become even more complex (Cadavero et al., 2024). In the United States, problems in recruitment and staffing, exacerbated by the COVID-19 pandemic, mean that many newly hired nurses encounter task structures that differ from those typical just half a decade ago, involving more elaborate interactions with technology and more patients per nurse (American Nurses Foundation, 2022; Jedwab et al., 2023). Many new nurses enter settings with higher overall employee turnover rates (National Council of State Boards of Nursing, 2023) or shorter orientation periods (Metersky et al., 2025) than were typical in the past, as well as reduced availability of ancillary and interdisciplinary support personnel (Twenter, 2024). In the context of electronic record-keeping and increased capacity for large-scale data trending, nurses are also subject to more intensive monitoring of workflow and time management than was typical in past eras (Frennert et al., 2023). With changes in the ownership and financial structure of healthcare organizations, many also work under heightened institutional pressure to reduce costs (Khullar et al., 2020). Nurses today are believed to confront an increased likelihood of being targeted by violence at work (Pariona-Cabrera et al., 2020), and, in an era of social media, are scrutinized by patients and families in ways unknown to earlier generations (La Regina et al., 2021). The aging of the population, moreover, has changed the nature of hospital care, with longer emergency department wait times, persistent overcrowding, and a high proportion of beds occupied by older and highly medically complex patients (Naik et al., 2024; Sifnugel et al., 2025).

These changes have created a complex material, interpersonal, and ideological landscape for new nurses to build their understanding of what it means to be a nurse. In the post-COVID era thus far, however, while some studies have focused on the beliefs and cultural outlook of “Gen Z” nurses (Lee & Ji, 2025), there has been relatively little in-depth empirical research on what young nurses experience as they construct a sense of professional identity during the early stages of the transition from school to work. Several authors (Payne et al., 2026; See et al., 2023) have identified a need for research in this understudied context.

To help address this gap, the aim of this qualitative narrative study was to explore the structure and content of newly graduated nurses’ stories about the first few months of the transition to practice. The findings shed light on the concerns of an emerging generation of nurses and their early processes of professional identity development and can help enhance understanding of contemporary retention trends.

Study Design and Methods

The study employed a longitudinal narrative analysis design based on the work of Riessman (1993). Riessman’s approach posits that narratives are venues for personal sense-making. Through stories they tell both to themselves and others, individuals actively construct identities, rhetorically assigning meanings to people, places, and things in their lives and situating themselves in relation to their circumstances and contexts. Narrative analysis calls the researcher’s attention not only to the informational content of stories but also to the structuring and temporal ordering of story elements, the motifs and themes that recur as stories are told, and the social purposes of storytelling. As Riessman (1993) observed, attention to performative elements of self-presentation in stories enables a researcher to understand the meanings people assign to symbols and situations. This approach is grounded in a constructivist epistemology which views narratives not as objective accounts but as interpretive reconstructions through which people present themselves as they wish to be understood (Riessman, 2008). As the aim of the study was to explore how newly licensed nurses assign meanings to their experiences, Riessman’s narrative approach was deemed the most appropriate methodological choice.

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.

Theoretical Framework

In research and policy focused on transition to practice, professional identity is a highly contested construct which has been conceptualized in sometimes conflicting ways (Cornett et al., 2023). In nursing in the United States, it is often framed as the acquisition of prescribed competencies, traits, values, or dispositions. This is exemplified by the American Association of Colleges of Nursing (AACN, 2021) competencies-oriented definition of nursing professional identity as a blend of “accountability, perspective, collaborative disposition, and comportment” (AACN, 2021, p. 43) and by survey tools recently developed to measure attainment of professional identity elements (Landis et al., 2024; Kaiser et al., 2026). Varpio et al. (2025) have characterized this as the “fitting a mold” approach.

In contrast, a more dynamic, social-constructionist approach is often favored by researchers working within a social sciences framework. This is exemplified by Patricia Benner, whose phenomenological conceptualization of “formation” (Benner, 2011) posited professional identity not as a static list of traits to be acquired or competencies to be mastered, but rather as a structure of consciousness, an evolving sensibility constituted and re-constituted by nurses through ongoing interactions with people, places, and problem-solving challenges. Similarly, in the field of organizational studies, Alvesson et al. (2008) have conceptualized “identity work” as the process by which professional identities are discursively formed, maintained, revised, and repaired through individuals’ micro-level interactions with workplace structures, ideologies, and power relationships framed by broader political-economic trends.

Several previous studies of nursing transition to practice have been grounded in this epistemological orientation, including Payne et al.’s recent examination (2026) of COVID-era healthcare discourses. Ten years ago, Traynor and Buus (2016) described how students discursively positioned themselves as “good nurses” by telling stories emphasizing their solidarity with one another against the backdrop of “bad” nursing observed in others. In taking a similar theoretically grounded approach here, we treated interviews as sites of identity work, listening for how new graduates presented themselves, interpreted the meanings of interactions and events on their units, and inscribed their experiences with moral significance.

Results

Ten new graduates responded and met the inclusion criteria regarding work start dates and hospital type. All were female, eight were below the age of 25, and the others were a year or two older. They worked at five different hospitals affiliated with three different regional hospital networks. In open-ended questions asking for racial and ethnic self-identification, one described herself as Black, one as Hispanic Black, two as non-Black Hispanic, two as White, one as Armenian-Caucasian, one as Chinese, one as Dominican of mixed ancestry, and one as Asian-Filipino, a diversity that was not surprising given the region’s overall demographic mix and nursing student population. The first round of interviews ranged from 45 to 87 min, with an average of 64 min. The second round ranged from 77 to 107 min, with an average of 94 min. Two participants dropped out between the first and second rounds. About 1,200 pages of transcripts were generated.

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.

Discussion

The transition to practice has long been understood as a challenging time, since it presents moral dilemmas and unexpected deviations from practice ideals precisely as new nurses are trying to build a feeling of belonging and a sense of professional self. Changes in the structure and culture of healthcare in recent years, however, particularly since the COVID-19 pandemic, have made aspects of the transition to practice even more complex today than in decades past. Exploring new graduates’ stories of entering contemporary contexts of care, this study shed light on the concerns of an emerging generation of young nurses. By treating interviews as sites of nurses’ identity work, venues where new graduates presented themselves and ascribed meaning to their experiences, the study’s narrative approach highlighted how contemporary practice conditions framed nurses’ processes of identity construction. Our findings thus provide a new perspective on factors which may be impacting retention trends and call attention to the need for a rethinking of what constitutes transition support for graduates entering their first professional roles.

All the new nurses in our study expressed pride in their accomplishments and presented themselves after several months as successful, eager learners deriving deep personal satisfaction from their evolving clinical skills. But the same sense of themselves as skilled nurses, paradoxically, meant portraying healthcare institutions as places which made important aspects of nursing virtually impossible. At the start of their professional lives, the nurses in our study wanted to associate nursing identity with honesty, caring, competence, relationship-building, team collaboration, courageous communication, and complex analytic thinking about clinical problems and their causes. What they learned in the first few months was that institutional conditions can disincentivize or discourage these. An “informal curriculum” (Hafferty & O’Donnell, 2014) became evident to them, conveying lessons about the financial priorities of U.S. healthcare, the position of nursing within healthcare organizations, and the complex interpersonal and institutional conditions that constrain nurses’ ability to enact the values they associate with professional nursing practice.

The new graduates in this study entered clinical practice with a combination of enthusiasm, excitement, and trepidation, and all expressed a keen awareness of maturing on the job. But all described encounters which not only deviated from idealized expectations of hospital life and work, as has been documented in previous decades of transition-related research, but also appeared to them to be plainly unjust and untenable. Where staffing and budgets were being cut, clinical support services were being eroded, and preceptors had less than a year of clinical experience, Danielle found it difficult to imagine long-term commitment to the job. Gianna saw how complex, multifactorial organizational problems were reframed as stories of individual blame, with managers advancing narratives that obscured broader system failures and foreclosed more frank discussion of causality in adverse events. Irene found nurses were expected to provide an institution with free labor. Ellen learned that when faced with the prospect of staying past their shift or getting entangled in complicated situations, people in higher-status positions – even other nurses – could betray, abandon, or humiliate nurse coworkers. Abigail discovered that taboos exist which discourage honest and forthright conversations about error. And Fiona encountered tacit norms in which people can pretend not to see what is directly in front of them.

In a recently published study of nurse retention, Pyhäjärvi and Söderberg (2024) found that new nurses experienced a series of corrosive disappointments, ethical tensions, and unfulfilled expectations which ultimately led them to feel a psychological “breach of contract” – a sense that a silent agreement had been violated, making the work of nursing untenable. These feelings did not result from a single incident but developed over time, leaving nurses with a feeling that the job is not sustainable. Similarly, Jackson et al. (2026) have argued that discursive practices in contemporary institutions individualize system failure, obscuring structural responsibility and intensifying the moral and emotional strain experienced by staff. Our findings affirm and build on this work. Although the new nurses in our study remained employed at 4 months and expressed pride in their clinical skill, a noticeable breakdown in optimism was evident. Their stories of disappointment and constraint support Yarahmadi et al.’s (2025) assertion that legal-ethical tensions in hospital care are not isolated moral dilemmas but systemic conditions that erode professional identity and resilience.

Compared with findings from earlier studies of transition to practice, the findings here suggest both continuity and change. Nurses in this study reported heavy workloads and staff shortages. These were consistent with research from previous decades and also with what has been reported in more recent, post-COVID scholarship (Cho et al., 2023; Church et al., 2023; Strouse & Radtke, 2024; Zipf, 2025). They also described inadequate support from ancillary personnel, as has been recently reported elsewhere (Twenter, 2024), heightened incidence of violence and aggression from patients and families (Pariona-Cabrera et al., 2020), and reliance on inexperienced preceptors as well as inconsistency and high turnover in preceptor assignments (Cadavero et al., 2024; Metersky et al., 2025). On the other hand, the implementation of structured orientation programs has also changed contemporary practice transitions compared to those of the past. Nurses in our study reported increased personal clinical confidence in the first few months which was at least partly connected to their engagement with formal precepting and support structures. This is consistent with other recent studies (Eckerson, 2018; Hampton et al., 2021; Thompson et al., 2025). They also found comfort working alongside similar-age peers, which aligns with recent observations by Chacón-Docampo et al (2026), who found new nurses experienced peer relationships as a “protective shield” offering emotional camaraderie and sense of affirmation during transition, even in an environment where unrealistic work demands overwhelmed capacity and training resources were inconsistent both in quality and quantity. Most importantly, however, was that their observations of the work environment involved more than shock about overwhelming workloads, pervasive work shortcuts, or feelings of burnout or self-doubt. Rather, the nurses described situations which violated their basic sense of fairness.

In a review of research on organizational efforts to promote new graduates’ readiness for practice, Masso et al. (2022) found that much attention has been paid to education and training strategies that build nursing skills. But instead of asking whether new graduates are ready for the workplace, the authors suggested, researchers might ask, more productively, whether workplaces are genuinely ready for nurses. What nurses need even more than additional training, they suggested, might be more genuinely supportive organizations. Our findings reinforce this perspective and raise questions about what constitutes meaningful transition-to-practice support. In the hospitals where our interviewees worked, orientation programs appeared to be largely skills-focused. The nurses reported high clinical acuity in their units and many opportunities to learn new skills. But their orientation programs did not facilitate discussion about the structural conditions of nursing work or provide them with opportunities to openly express or explore the moral disappointments, ethical tensions, or professional dilemmas which were most important to them. At the same time that they developed clinical confidence, in essence, they also became highly cognizant of lacking power to openly discuss unsafe and sometimes unpredictable staffing conditions, demand forthrightness and nuance in narratives about the root causes of clinical failure, question the expectation of uncompensated labor, or advocate for system-level change.

Research continues to indicate the benefit of caring, emotionally supportive relationships between preceptors and preceptees (Omer & Moola, 2019). However, our findings also suggest that in the current climate, caring relationships may not be sufficient. Relationships alone cannot cultivate a workforce proud of its professional identity under the working conditions that characterized bedside practice as experienced by the participants in our study. Moreover, what is sometimes interpreted as a generation-specific attitude toward work and job commitment (Lee & Ji, 2025), we suggest, may instead reflect generational intolerance of organizational inconsistency and perceived hypocrisy.

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.

Limitations

Several limitations must be noted. Participants for this study were recruited from a single, highly urbanized, ethnically and economically diverse U.S. state. Conditions faced by new nurses in other geographic regions in the U.S. or in other nations may be different, perhaps in some cases even more challenging. Although the interviewees were racially and ethnically diverse, no male volunteers met the enrollment criteria. The study thus lacked gender diversity, a significant shortcoming at a time when increasing numbers of men are entering the nursing profession. Moreover, all participants were first-career BSN graduates working in medical–surgical settings. New graduate nurses from different educational pathways, such as second-degree programs, might report different experiences, as might new graduates working in other practice areas, such as outpatient clinics or emergency departments.

Conclusion

Using a narrative analysis approach, this longitudinal qualitative study examined newly licensed nurses’ stories about the transition to practice. In stories they told about hospital life, the nurses rhetorically presented themselves as they believed nurses should be seen, and they also conveyed profound disappointment with institutions that constrained their ability to enact values they ascribed to nursing, such as honesty, team collaboration, courageous and forthright communication, and serious analytic engagement with complex problems. Portraying healthcare institutions as places that render these aspects of nursing impossible, their narratives illuminate how contemporary practice conditions frame processes of identity construction. This study underscores that the challenges facing newly graduated nurses are not rooted in a lack of preparation or commitment, but rather in the impossible conditions under which professional identity is being formed. Efforts to support new nurses’ transition to practice must move beyond individual skill development to address the conditions that make it difficult to enact core aspects of nursing.