Assessing validity and reliability of the Transition Shock Scale for Undergraduate Nursing Students (TSS, Chinese version) in associate degree nursing students

In recent years, the results of multi-country studies [1, 2] showed that nurse turnover rates were generally high, with 19.9% (voluntary departure from hospital or position adjustment), 13.9% (voluntary or involuntary departure from the hospital, excluding position adjustment), 36.6% (voluntary or involuntary departure from hospital and position adjustment) and 44.3% (voluntary or involuntary departure from the hospital, including post adjustment), and 12 to 21% of nurses in European countries left the hospital. In China, the “National Nursing Development Plan (2016–2020)” document emphasizes that there are problems such as the shortage and loss of nursing personnel in the development of the nursing industry during the “Twelfth Five-Year Plan” period [3]. As of 2021, the number of registered nurses in China is 5.02 million, with only 3.55 registered nurses per 1,000 population [4], which is still far from the minimum national health workforce requirement of 4.45 nurses per 1,000 population mentioned in the Global Strategy on Human Resources for Health: Health Workforce 2030 (WHO) [5].

Clinical internship is the starting point for nursing students to have real contact with the clinic and go to society [6]. Notably, nursing interns are the future successors of nursing careers. Clinical practice allows nursing interns to apply the theoretical contents they have learned in school directly. It is a process in which students can integrate and participate in knowledge and practice. However, nursing interns are not licensed. Many nursing interns become nervous because of the unfamiliar hospital environment during clinical practice, feel the difference between the theoretical content learned at school and clinical practice, and experience an immature role performance and lack of confidence due to insufficient knowledge [7, 8], and appear confused and overwhelmed, i.e., transition shock [9]. Relevant studies [10, 11] have also demonstrated that if nursing interns fail to deal with transition shock during the clinical placement phase, they may drop out of the nursing profession at the end of their clinical placement.

Transition shock has emerged as the experience of moving from the known role of student to the relatively less familiar role of a professionally practicing nurse [9, 12‐14]. Studies related to transition shock have been carried out in many countries but primarily focus on the transition shock of new nurses [15], while transition shock in nursing interns has been less frequently reported. In contrast, nursing students have just left campus during their internship, transitioning from student to nurse roles. Nursing students do not have the knowledge and skills that nurses should have, and they will encounter many difficulties and pressures in nursing work, and if they cannot adapt in time, transition shock can occur. Previous studies related to the clinical practice of nursing students are mostly quantitative studies that restrictively identify specific variables such as clinical practice stress, satisfaction, emotional labor, and self-esteem [15‐17]. In addition, most of the previous studies related to transition shock were quantitative [8, 18], and the transition shock measurement tool was developed for new nurses [19]. However, important differences exist between nursing interns’ and new nurses’ roles and responsibilities. Existing tools have not considered nursing students’ characteristics because their questions presuppose that nurses are licensed to perform medical practices as members of the workplace. However, nursing students typically practice observation, and existing tools measure excessive work [6]. Therefore, there is a need for more targeted assessment tools to measure the degree of transition shock of nursing interns.

In 2018, Korean scholars Kim and Shin [20], based on transition shock theory, developed the Transition Shock Scale for Undergraduate Nursing Students (TSS), with good reliability and validity. Notably, it has been applied in several foreign studies [20‐23], and it is a mature scale for evaluating transition shock for undergraduate nursing students [23]. In 2021, Huang et al. [24] Chineseized the scale to include six dimensions: conflict between theory and practice (Item1 ~ Item3), an overwhelming workload (Item4 ~ Item6), loss of social support (Item7 ~ Item8), diminishing relationship with a co-worker (Item8 ~ Item11), confusion in professional nursing values (Item12 ~ Item16), and incongruity in work and personal life (Item17 ~ Item18). The Likert 4-point scale was used, ranging from “strongly disagree” to “strongly agree,” with scores of 1–4 and 18–72, respectively, with higher scores indicating greater transition shock. The Cronbach’s α coefficients of the Chineseized scale as a whole and each dimension were > 0.6, and the scale’s content validity was 0.987 (> 0.9).

Different from other countries, the academic qualifications of clinical nurses in China are mainly associate degrees [4]. The gap between the undergraduate and associate degree levels of education has led to differences in nursing students’ study time and learning content, four years for undergraduates and three years for associate degrees. Importantly, associate degree courses focus more on practice and less complex theoretical content. At the same time, undergraduate courses emphasize theoretical knowledge, so undergraduate nursing programs produce more well-rounded students [4]. There is no scale for evaluating the transition shock of nursing interns, and the applicability of other scales for evaluating the transition shock of new nurses to nursing interns is unknown. Meanwhile, there is a lack of research on applying the TSS (Chinese version) to the transition shock of associate degree nursing interns. Therefore, this study used the scale to associate degree nursing students to examine the scale's reliability in assessing the degree of transition shock among nursing interns.

This methodological validity study was conducted in the Hunan Province, China. The researcher collected the data in person after the study participants filled out the questionnaire. This article followed the STROBE checklist for cross-sectional studies.

Given the impending global nursing shortage and the impact of the low retention rates cited in the report [32], there is a need to consider the safety of nursing interns about to enter the workforce and the stress factors affecting their transition to practice. Related studies have pointed out that transition shock is positively correlated with the turnover rate of new nurses, i.e., the higher the degree of transition shock of new nurses, the higher their turnover rate [10, 11]. As clinical internships are a critical stage in the transition from student to clinical nurse, a high transition shock may also lead to the idea of a career change [16]. Therefore, early assessment of the transition shock level of associate degree nursing interns and timely targeted interventions are essential to stabilize and expand the nursing workforce. As associate degree nurses are an important part of nursing team [4], we should pay attention to the transition shock level of associate degree nursing students.

It is necessary to consider a measurement instrument’s reliability and validity. The Cronbach’s α coefficient measures the homogeneity and internal consistency of the items on the scale [33]. A high Cronbach’s α coefficient means that the items on the scale are consistent with each other on that scale and that the scale is composed of items that focus on the same factor. In establishing a scale’s reliability level, it is recommended that in conditions where the item scores in the item solution are continuous (Likert-type), Cronbach’s α coefficient should be calculated [33, 34]. The results show that TSS (Chinese version) has high internal consistency (Cronbach’s α = 0.925) in associate degree nursing interns and is a valid and reliable instrument for associate degree nursing interns evaluating the level of transition shock. Furthermore, Cronbach’s α coefficients for the scale and each dimension were > 0.9, indicating good reliability [35].

Content validity refers to the degree to which the item sample in the measurement tool can properly reflect the concept to be measured. The establishment of content validity in the scale development is mainly realized through two stages: 1) Scale development stage: including dimension definition, item generation and scale construction; 2) Evaluation stage of content validity: The idea is to ask experts to judge the degree of agreement (relevance) between the items of the scale and the original content range [34, 36]. Eight experts in nursing education and nursing administration were consulted for this study, and the results showed that the I-CVI ranged from 0.875 to 1.000 and the S-CVI was 0.951. Moreso, it demonstrated that the TSS (Chinese version) has good content validity.

EFA and CFA were performed for the construct validity of the scale. The KMO value of this study was calculated to be 0.936, indicating that the data samples used in this study were sufficient and suitable for factor analysis [27]. This study revealed three common factors through exploratory factor analysis and the four dimensions of the original scale loss of social support, diminishing relationship with co-workers, confusion in professional nursing values, and incongruity in work and personal life into one common factor. From the correlation between the dimensions in Table 5, the correlation coefficients of the above four dimensions ranged from 0.606 to 0.772 (p < 0.01). The four dimensions were noted as interrelated and influenced each other. As associate degree nursing interns step into clinical practice, the loss of social support and loss of social support results in incongruity in work and personal life, leading to confusion in professional nursing values [6]. Dai et al. [37] also investigated the mediating effect of career identity between career resilience and transition shock among intern nursing students, and the results of the study showed that intern nursing students with high career identity also had higher career resilience, along with lower levels of transition shock. This study further illustrates that the relationship between nursing values, social support, interpersonal relationships, and transition shock is interrelated and mutually influential for intern nursing students, consistent with the results of Cao et al. [38]. Meanwhile, the study found that the lack of social support and interpersonal tensions experienced by nursing specialty interns during the clinical placement process can lead to confusion about nursing values and difficulty reconciling between personal life and clinical practice, Ko YJ et al. also discovered this phenomenon based on phenomenological research methods [39]. This highlights the importance of providing adequate social support and reducing interpersonal tensions to ensure a successful clinical placement. According to Duchscher’s [9] Stages of Transition theory, the assessment of the degree of transition shock requires a separate evaluation of the four dimensions of loss of social support, diminishing relationship with co-workers, confusion in professional nursing values, and incongruity in work and personal life so that nursing educators can develop targeted intervention plans for them. Therefore, this study also maintained the original scale’s division of the 6 dimensions.

CFA results showed acceptable fitness values after the model correction (Modification Indices, MI). Notably, Huang et al. [24] did not use factor analysis to determine the construct standards of the scale after the scale was translated into Chinese. MI represents the minimum cardinality value reduced under model re-estimation after a previously fixed parameter is released. Statistically, an MI can be interpreted as the cardinality distribution of one degree of freedom [40]. Since the critical statistical value of the chi-square for one degree of freedom (d = 0.05) is 3.84, an MI value greater than 3.84 is considered large enough to be released and re-estimated if there is sufficient theoretical support for the causality of this parameter. Before the model correction, χ2/df = 5.126 > 5, RMSEA = 0.072, and in-depth analysis of the model MI values, the highest MI value of 114.162 was found for the path “e15 ← → e16”, indicating a close relationship between the two. After correlating the two in the model, χ2/df = 4.064 < 5, which is acceptable. Analyzing the reason, both Item 15 and Item 16 were used to assess the content of the nursing professional values confusion dimension, and both were expressed with emotions such as distress and uneasiness, so the association was high. Under this consideration, the variables of e15 and e16 were released first, then checking the fitness changes. Importantly, the results show that after releasing e15 and e16, all their fit indices are acceptable.

The correlations (range 0.344—0.772) between all domains of TSS (Chinese version) were positive and significant, confirming the discriminant validity. The strongest correlations were found between confusion in professional nursing values and incongruity in work and personal life, and lower correlations were found between conflict between theory and practice and loss of social support. Thus, it may be inferred that the greater the confusion in professional nursing values, the worse the incongruity in work and personal life and the greater the transition shock of nursing interns [21]. Moreso, Keszei, et al. [41]. investigated the current status of transition shock among nursing interns and its correlation with professional identity, and the results showed that nursing interns with high professional identity had low transition shock, which is consistent with the results of this study. This suggests that nursing educators and administrators can stabilize nursing teams by helping nursing interns establish good professional identity, thus alleviating the degree of transition shock of nursing interns during clinical practice [42].