2.1. Design & setting

We applied a cross-sectional survey study design to investigate nursing students’ transition shock during internships in four Chinese tertiary Class A hospitals. These hospitals are among the most prestigious medical institutions in the region, known for their advanced medical services, extensive training programs, and high patient volumes. Their selection is particularly pertinent to this study as they represent high-quality clinical environments where nursing students experience a wide range of complex and challenging situations. By focusing on these leading hospitals, this study aimed to provide a comprehensive understanding of transition shock and adaptation processes faced by new nursing graduates in demanding and resource-rich settings. In addition, it is worth noting that in China, nursing higher education is provided at two levels: nursing education at the junior college level and at the bachelor level. In general, junior college nursing students learn clinical knowledge and skills for three years, while undergraduate nursing students require four years. All educational programs include internships for at least eight months of clinical practice and give access to the same nursing certificate. However, junior college nursing education focuses on cultivating students’ clinical practice skills, while undergraduate education aims to develop students’ clinical critical thinking and cultivate applied talent.

2.2. Participants & recruiting

Interns were eligible for participation if they met the following criteria: ① Aged ≥18 years; ② enrolled in nursing education;③ engaged in an internship. Participation was not part of the formal clinical placement assignments and was therefore voluntary [19]. The management of the nursing schools and hospitals was blinded with regard to whether students participated.

We provided instructions containing all the information necessary to make a decision about participating in this study (i.e., the introduction and objective of the study, the required time to complete the questionnaire, confidentiality, expectations, and rights). After reviewing the information, interested individuals provided written informed consent before participating. To maximize participation, follow-up communications were conducted to address any additional questions. The online questionnaire link was distributed to nursing students during their internship in four tertiary Class A hospitals by nursing staff who were unfamiliar with the research using their usual communication medium (WeChat or another online platform). This approach leveraged the convenience and accessibility of online data collection, which not only facilitated a broader reach but also allowed for real-time data gathering and reduced the potential for response bias.

2.3. Survey

The complete questionnaire comprised two sections: demographics and the transition shock scale. Demographic data were collected in a manner designed by the researchers and included gender, age, educational background, family status, whether the respondent was an only child, the scale of the respondent’s school, the grade of the hospital where the respondent practiced, the respondent’s first choice of major for the college entrance examination, clinical practice, nursing attitude, and development intention after graduation. The demographic section consisted of multiple-choice questions and fill-in-the-blank questions, with uniform instructions to explain the concepts, meanings, and methods of providing demographic variables. For example, The "school scale" referred to a key university, first batch of university, second batch of university and junior college as assessed by the Ministry of Education; and the grades of the practicing hospitals were grade III, grade II, grade I and ungraded as assessed by the Ministry of Health.

The transition shock scale was used to measure reality shock for nursing students and was modified and validated by Kim and Shin. The original scale was developed by Kim et al. to measure newly graduated nurses’ transition shock. After sinicization, it consisted of 18 entries across six dimensions: conflict between theory and practice (3 entries), overwhelming practicum workload (3 entries), loss of social support (2 entries), shrinking interpersonal relationships (3 entries), ambiguity in professional nursing values (5 entries), and incongruity between clinical practicum and personal life (2 entries). Each item was rated on a 4-point Likert scale (1 = “strongly disagree”; 2 = “disagree”; 3 = “agree”; 4 = “strongly agree”). The total score ranged from 18 to 72, with a higher score indicating greater transition shock during clinical practice. Regarding this scale, the content validity indices (CVI) of all items were > 0.78, and the scale-level content validity indices (S-CVI) of 0.987 were the acceptable standard. The reliability coefficient (Cronbach’s alpha) of the scale was 0.912, and the range of every dimension’s reliability coefficient (Cronbach’s alpha) was 0.657–0.887. The computed Cronbach’s alpha based on the data collected from our study was 0.919, indicating acceptable reliability.

2.4. Data collection

Data were collected using an online survey platform (Wenjuanxing), which guaranteed adherence to all regulations and legislation regarding data protection.

Convenience sampling was used to select nursing students during their internships from four tertiary Class A hospitals in Changsha as the research object. The inclusion criteria were as follows: 1) full-time nursing intern; 2) more than or equal to 2 weekends of clinical practice; 3) voluntary consent from the participant; and 4) general cognitive and understanding ability. The exclusion criteria were nonclinical nursing care providers due to illness or other matters. Considering that the regression analysis method was selected for this study, the sample size was recommended to be at least 10 times the number of explanatory variables [20].

To ensure the reliability and validity of the data, we implemented several quality control measures. Each participant could submit the survey only once per account. We also set a minimum completion time of two minutes based on preliminary testing; responses completed in less than this time were flagged and excluded. Additionally, the platform was secured with password protection, and attention-check questions were included to identify and remove careless responses. A total of 620 questionnaires were sent, and 56 were eliminated due to irrational answers or unreasonable internet protocol addresses. Ultimately, 564 valid questionnaires were returned, for a response rate of 90.3%. The recycling of questionnaire data was applied to test the structural validity, item differentiation, and internal consistency of the scale.

2.5. Data analysis

The data were analyzed using SPSS Statistics 26.0 (IBM Corp., Armonk, NY, USA). The normal distribution of the study variables was confirmed using the Kolmogorov‒Smirnov test (p > 0.05). Frequencies and percentages were computed to describe the enumeration data, such as participants’ gender and family situation. The average, standard deviation (SD), median, lower quartile (P₂₅), and upper quartile (P₇₅) were used to describe the measurement data, such as the time of clinical practice and the total scores of the scale. The Mann‒Whitney U test and Kruskal‒Wallis H nonparametric analysis were applied to compare the score differences in the transition shock of nursing students with various sociodemographic characteristics. Spearman’s correlation analysis was used to examine the correlations among the study variables. In addition, multiple linear regression was used to analyze the influencing factors of the transition shock of nursing students.

2.6. Ethical considerations

Prior to data collection, the study protocol was approved by the relevant institutional review committee (Approval was granted by the Ethics Committee of Xiangya Hospital, Central South University with registry number 2022100820). Written informed consent was obtained from each individual participant prior to the survey. Participants were informed that participation was voluntary, that their anonymity was guaranteed at all times, and that the collected data would only be coded into numbers. Moreover, no incentives were offered to the participants. All methods were performed in accordance with the Declaration of Helsinki guidelines (World Medical Association, 2013).

3.1. Sociodemographic characteristics of the sample

A total of 564 nursing students from four tertiary Class A hospitals in Changsha participated in this study. A total of 499 of them, accounting for 88.48%, were female, and 65 of them, accounting for 11.52%, were male. The age of the respondents ranged from 18 to 30 years, with a median of 21 years. According to the results of the nonparametric analysis, nursing students with different monthly household incomes, school scales, future plans, attitudes toward nursing, and first choice of major had different scores for transition shock. The difference was statistically significant (p < 0.05). Further details are provided in Table 1.

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Table 1. Comparison of transition shock scores of nursing students with different sociodemographic characteristics (N = 564).

https://doi.org/10.1371/journal.pone.0313524.t001

3.2. The total score of the transition shock scale and the score of each dimension

The total score of the transition shock scale of nursing students was 46 (41,52), and the specific scores of each dimension are detailed in Table 2.

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Table 2. The total score of the transition shock scale and the score of each dimension (N = 564).

https://doi.org/10.1371/journal.pone.0313524.t002

3.3. Correlation in every dimension of the transition shock scale with other variables

There was a positive correlation between nursing students’ attitudes toward nursing and the dimension of conflict between theory and practice (r = 0.120, p = 0.004). There were positive correlations between the number of night shifts and the dimension of overwhelming practicum workload (r = 0.128, p = 0.030), between the workload dimension and the first choice of major (r = 0.132, p = 0.002), and between attitude and the workload dimension (r = 0.197, p < 0.001) among the nursing students.

In addition, attitude toward nursing (r = 0.256, p = 0.02) and first choice (r = 0.113, p = 0.007) were positively correlated with the dimension of loss of social support. For the dimension of shrinking interpersonal relationships, nursing students’ attitudes toward nursing (r = 0.322, p < 0.001), future plans (r = 0.104, p = 0.014), and first choice (r = 0.191, p < 0.001) were positively correlated. There were negative correlations between nursing students’ educational background and the dimension of shrinking interpersonal relationships (r = -0.104, p = 0.013) and between the school scale and the relationship dimension (r = -0.140, p = 0.001).

Attitudes toward nursing (r = 0.487, p < 0.001), future plans (r = 0.127, p = 0.002), monthly household income (r = 0.111, p = 0.009), and first choice (r = 0.286, p < 0.001) were positively correlated with the dimension of ambiguity in professional nursing values among nursing students. In addition, student leader experience (r = 0.131, p = 0.002), attitude toward nursing (r = 0.385, p < 0.001), future plans (r = 0.127, p = 0.002), and first choice (r = 0.197, p < 0.001) were positively correlated with the dimension of incongruity between clinical practicums and personal life. Further details are provided in Table 3, and the assignment of enumeration data is shown in S1 Table.

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Table 3. Correlation in every dimension of the transition shock scale with other variables (N = 564).

https://doi.org/10.1371/journal.pone.0313524.t003

3.4. The influencing factor analysis of transition shock in nursing students

Measurement data with statistical significance and enumeration data with set dummy variables were subjected to multiple linear regression analysis. It was clear that the influencing factor for transition shock in nursing students was their attitudes toward nursing. Further details are provided in Table 4, and the assignment of enumeration data is shown in S2 Table.

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Table 4. Multiple linear regression analysis of transition shock in nursing students (N = 564).

https://doi.org/10.1371/journal.pone.0313524.t004

4.1. Nursing students’ transition shock was moderate

This study is accompanied by a preprint resource [21]. The investigation revealed that within this survey, the overall score of nursing students’ transition shock was moderate 46 (41, 52), with a median entry score of 2.56 (2.28,2.89). The results were similar to those of Wang et al. [11] and lower than those of Kim et al. [22] from Korea. This may be related to the source of the study subjects, the way nurses are trained, the healthcare environment, and the underlying national context in different countries. Currently, increasing research emphasizes the significance of transition shock. Studies by Li et al. [23] have shown that transition shock has a significantly negative influence on the humanistic practice ability of newly graduated nurses. Nursing managers and educators can mitigate the adverse effects of transition shock by enhancing the benefits of organizational socialization programs, ultimately improving the humanistic practice abilities of newly graduated nurses. This underscores the necessity of ongoing efforts to enhance support systems and educational practices, thereby facilitating smoother transitions and better equipping students for their professional roles.

4.2. The influencing factors in each dimension of the transition shock scale were different

The transition shock scale contained six dimensions, and each dimension had a different degree of impact on nursing students. According to the results of the correlation analysis, the influencing factors of each dimension were different.

4.3. Attitude toward the nursing profession had an independent influence on nursing students’ transition shock

The results of this study showed that attitude toward the nursing profession had an independent influence on nursing students’ transition shock. The more nursing interns enjoyed nursing, the lower their level of transition shock and vice versa, with a significant correlation. According to self-concordance theory, individuals’ behavior is guided by their decisions, which are bound by internal characteristics and the external environment. When the external environment is in line with the internal characteristics of individuals, individuals will see work as a kind of self-expression, which leads to a positive work attitude [34]. Our findings indicate that nursing undergraduates who possess a positive attitude towards their career aspirations and a sense of congruence between these aspirations and their academic experiences report lower levels of transition shock. What’s more, transition shock theory, which examines the process of adaptation during periods of change, provides a complementary perspective. The theory highlights how positive attitudes towards the nursing profession—such as enthusiasm for the field and commitment to professional development—affect individuals’ experience during the transition period. Our study finding also aligns with Transition Theory’s emphasis on the importance of positive attitudes and supportive systems in facilitating successful adaptation during transitional phases. Therefore, the social environment greatly affects nursing students’ attitudes toward the nursing profession. University education should help students build beliefs, while the clinical learning environment connects university study and clinical placements. A study showed that an environment that positively influences the choice of a future career allows nursing students to adapt quickly to the clinical pace [35]. Therefore, it is necessary to pay more attention to improving the education strategy and the practice plan and to focus more on two-way feedback.

4.4. Limitations

First, this study used a convenience sampling method, which may have led to large discrepancies and potential response bias, potentially affecting the generalizability of the findings. To address this limitation, future research could utilize random sampling techniques to reduce bias and enhance the external validity of the results. Additionally, replication studies in diverse settings are needed to validate and extend these findings. Second, the cross-sectional design of the study could only provide a temporal snapshot of transition shocks at a given point in time. To capture the dynamic nature of transition shock, a longitudinal study design could be employed to track changes over time. Third, the study used a single research method, which was limited by many objective factors. Moreover, no intervention was implemented in this study. A qualitative study or longitudinal survey could be conducted subsequently. Fourth, the participants were all from tertiary A hospitals in Changsha, so the findings were limited to one region. It is recommended that researchers conduct a multi-regional, national survey with a large sample size to develop normative data for the transition shock scale.

4.5 Implications for nursing & health policy

According to the results of the study, improving nursing students’ enjoyment of nursing may be meaningful for managing their transition shock. Therefore, nursing managers ought to strengthen the publicity of the nursing profession, so that more people can correctly understand the nursing industry, and improve the social recognition and authority of nursing. At the same time, more career development opportunities such as participating in academic conferences and scientific research projects should be provided, so as to give nursing students a broader space for growth. Nursing administrators should establish a sound training management mechanism, appropriately balancing the ratio of nursing students with leadership experience to others in internship groupings and on-call assignments, while fostering an environment where student leaders can exemplify leadership and support their peers during clinical practice. Taking the initiative to encourage students to relax, create a harmonious and pleasant atmosphere as well as focusing on the development of cooperation skills will also beneficial to their interpersonal relationships. Worth noting is that our findings could inform healthcare policy by emphasizing the importance of supportive frameworks for managing transitions, potentially guiding policy development to better support nursing professionals throughout their careers.