‘Navigating the uncharted waters’- Transition experiences of novice advanced practice nurses in China: A qualitative study

‘Navigating the uncharted waters’- Transition experiences of novice advanced practice nurses in China: A qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article ‘Navigating the uncharted waters’- Transition experiences of novice advanced practice nurses in China: A qualitative study Wei Tan, Qin Hu, Shanshan Liu, Cong Wang, Lei Wang, Yan Jiang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8879966/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Apr, 2026 Read the published version in BMC Nursing → Version 1 posted 13 You are reading this latest preprint version Abstract Background Transitioning to the role of advanced practice nurses is dynamic and challenging. Deeply exploring the transition experience and developing corresponding intervention strategies can make the transition smoother. China's development of advanced practice nursing remains at a nascent stage, exhibiting localized characteristics. However, limited knowledge exists regarding experiences, feelings, and challenges of advanced practice nurses in the region. This study aims to explore the transition experiences of novice advanced practice nurses in China. Methods A descriptive qualitative design was used. Twenty-three advanced practice nurses was recruited using purposive sampling technique. Semi-structured and face-to-face interviews were conducted to collect the data, and the thematic analysis was used to analyse the data. Results “Navigating the uncharted waters” was the overarching theme, which linked four themes: (1) being constrained by the practical environment; (2) reconstructing professional identity; (3) bearing multiple burdens; and (4) steering my own course. Furthermore, distinctive characteristics were identified among Chinese advanced practice nurses, specifically the phenomenon of "disguise" in their work practice and a strong aspiration for a graduate degree. Conclusions This study reveals that the role transition for advanced practice nurses is a complex and demanding process, profoundly shaped by the practical environment. The findings further highlight the importance of adaptive copingbehaviours, particularly personal resilience and proactive learning. Healthcare institutions, nursing organizations, and national policymakers should offer strong support by enhancing educational programs and developing transition plans, thereby creating a positive environment for advanced practice nurses. Trial registration Our study does not report healthcare interventions on human participants. Clinical trial number: not applicable. Advanced practice nurses Transition Experience China Qualitative study Figures Figure 1 1. Introduction The International Council of Nurses defines an advanced practice nurse(APN) as “a generalist or specialized nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for advanced nursing practice”[ 1 ]. To address the dual challenges of the continuous increase in healthcare demands and the ongoing shortage of healthcare professionals, the development of APNs has exhibited a global trend[ 2 ]. Currently, approximately 70 countries or regions have introduced APNs[ 3 ], and are at different stages of developing advanced practice nursing[ 4 ]. The value of APNs has been widely demonstrated. The evidence is substantial that APNs contribute to providing high-quality healthcare services[ 5 ], improving patient clinical outcomes and satisfaction[ 6 ], and reducing medical costs[ 7 ]. The development and implementation of new roles is never an easy task, and the transitional phase is particularly crucial[ 8 ]. For APNs newly entering the workforce, the transition to this new role is a dynamically changing and multi-challenging process, requiring them to master new knowledge and skills, shoulder new responsibilities, establish new professional relationships, and integrate into new practice areas[ 9 ]. Multiple international studies have shown that novice APNs encounter difficulties and obstacles, including low personal confidence, a lack of recognition from other healthcare professionals, and heavy work burdens[ 10 ]. These difficulties often lead to adverse consequences, such as negative emotions, low job satisfaction, job burnout, and even increased intention to leave[ 11 ]. It is evident that the transition to APNs is problematic[ 12 ]. A comprehensive understanding of the transition and looking at changes in transition can provide deeper insights into the “fuzzy logic of practice”, which is very helpful for facilitating the transition[ 13 ]. For example, a study constructed a theoretical model “from Limbo to Legitimacy” through qualitative interviews, describing common practice experiences in the transition to the primary care nurse practitioner role[ 14 ]. On the basis of this common experience, scholars subsequently organized targeted webinars, which were shown to positively influence the NP’s perceptions of role transition[ 15 ]. Therefore, deeply exploring the transition experience and developing corresponding intervention strategies can make the transition smoother. Internationally, given the importance of the transition experience, many scholars have conducted a series of studies on this topic, identifying some common phenomena and analysing related obstacles and promoting factors[ 16 ]. However, many participants in these studies have held the role of APNs for a long time, almost more than 1 year[ 17 ]. For example, a qualitative study of nurse practitioners who have been working in the Netherlands for 2 to 6 years revealed that they have achieved success and that role transition is driven by ambitions[ 18 ]. Existing research has primarily focused on their post-transition experiences and professional growth, while paying less attention to the transition process between old and new roles—particularly their initial clinical experiences after completing educational training programs. This may be attributed to the long recall period of the participants, as some of their early feelings may have faded from memory. As an innovative role that expands the boundaries of traditional nursing practice, the development of APNs in mainland China is still in the nascent stage. In the early 21st century, scholars began to explore this topic, but their discussions were limited to theoretical research, focusing on translating and analysing foreign concepts. Since 2010, the education and training of APNs, such as curriculum design, training objectives, and core competencies, has become a research hotspot[ 19 ]. Subsequently, several medical schools and healthcare institutions initiated pilot education programs[ 20 ]. In 2017, the Peking University School of Nursing enrolled students in the Nurse Practitioner Master's program in Chronic Disease Management[ 21 ]. In 2021, the West China Hospital of Sichuan University launched an in-service training program for APNs[ 22 ]. However, few practical studies exist, and few scholars have focused on the experiences and performance of APNs after they enter the workforce. Only one study has described the work experiences of APNs in the ICU, finding that they have unclear professional positionality and are prone to role conflicts[ 23 ]. There may be a disconnect between education and actual clinical practice, highlighting the need for further practical exploration to optimize training content and develop effective transition programs. Additionally, China’s social culture, healthcare system, and health service needs differ from those of other countries. There are also differences in nurses' social status, educational background, and staffing levels[ 24 ]. Although the Chinese Nursing Association has proposed starting an APN program, APNs have not yet been protected by law, and public awareness of their role is limited[ 25 ]. Therefore, APNs in mainland China follow a localized model, and their experiences may differ from those in other countries. Moreover, no Chinese scholars have yet researched the transition to APNs, making the exploration of this field even more urgent in mainland China. Therefore, this study aims to investigate the transition experiences of novice APNs in China and provide insights for developing educational programs and intervention strategies to support smooth transition. 2. Methods 2.1 Study design A descriptive qualitative design was used. This method helps to obtain comprehensive and direct descriptions of participants' experiences[ 26 ]. The reporting of this study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist[ 27 ] (Related File 1). 2.2 Setting and participants Purposive sampling was employed to recruit participants from two tertiary hospitals in mainland China. The inclusion criteria were: (1) completing the APN training curriculum;(2) being employed as an APN; and (3) assuming APN responsibilities for less than 1 month. Given the early developmental stage of the APN role in China and the absence of a unified national regulatory framework, training and certification are currently led by various entities, including professional nursing associations, academic institutions, and hospitals, resulting in considerable variability in standards. This first exploratory study on APNs in mainland China seeks to provide foundational evidence to clarify the role. The APN training program referenced in this study was based on a nationally developed core competency framework encompassing six domains: clinical care, consultation, coordination, leadership, teaching, and research[ 28 ]. The resulting curriculum comprised 36 modules (12 hours each). Certification required passing both theoretical assessments and an Objective Structured Clinical Examination (OSCE), administered by the participating hospitals. 2.3 Data collection A semi-structured interview guide was developed based on literature review, team discussions, and a pilot test with two participants (Supplementary File 1). Between September and December 2023, the first author conducted individual face-to-face interviews in a quiet hospital conference room, encouraging participants to freely share their experiences. Each interview was audio-recorded in Chinese, and field notes about participants' facial expressions and body language as well as the interviewer's reflections were compiled. Data saturation was achieved after the 21st interview, as no new information emerged. Two additional interviews were conducted to confirm saturation, resulting in a final sample of 23 participants. Interviews lasted 31 to 103 minutes (mean: 64 minutes). 2.4 Data analysis Braun & Clarke’s thematic analysis method was used, following six phases: familiarising yourself with your data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report[ 29 ]. Two authors read and reread the data for coding and then collated the codes into potential themes and subthemes. By holding regular team meetings, these themes were discussed and refined until a consensus was reached. Data were analyzed using NVivo 12.0. 2.5 Rigor The rigor includes four dimensions: credibility, transferability, dependability and confirmability [ 30 ]. All the interviews were conducted by the same author to maintain consistency and ensure data credibility. She is a PhD student in nursing with research experience in advanced nursing practice and qualitative studies, has a strong interest in the topic, and does not have any apparent biases or professional relationships with the participants. In addition, all interviews were audio-recorded and transcribed systematically to ensure credibility. A comprehensive presentation of the context, participants, and data collection and analysis procedures and a detailed description of the findings were provided to establish transferability. Dependability was ensured by using field notes and sharing transcribed data and preliminary analysis results with the participants. Two authors separately coded the transcription data and held regular meetings with other team members, further increasing the confirmability of the data. 3. Results Twenty-three participants aged between 32 and 50 years participated in this study. The majority of the participants were female (n = 21), and held a bachelor's degree (n = 18). The demographic characteristics are presented in Table 1 . Table 1 Demographic characteristics of the participants (n = 23). No. Age Gender Marital status Level of Education Nursing tenure (Years ) Practice area N1 32 Female Married Bachelor 14 Endoscopy N2 39 Female Married Bachelor 18 Urology N3 42 Female Married Master 23 Endocrinology N4 40 Female Married Bachelor 23 Geratology N5 39 Female Married Bachelor 20 General surgery N6 45 Female Married Bachelor 26 Geratology N7 41 Female Married Bachelor 22 Biological therapy N8 45 Female Married Bachelor 24 Orthopedics N9 35 Female Married Master 12 Endocrinology N10 50 Female Married Bachelor 26 Gastroenterology N11 40 Female Married Bachelor 20 Geratology N12 43 Female Married Master 23 Nephrology N13 45 Female Married Bachelor 25 Thoracic Oncology N14 35 Female Married Master 12 General surgery N15 39 Female Married Bachelor 21 Cardiovascular Surgery N16 39 Female Married Bachelor 19 General surgery N17 32 Male Married Bachelor 9 Endoscopy N18 37 Male Married Bachelor 18 Rehabilitation medicine N19 40 Female Married Bachelor 20 Lung cancer N20 41 Female Married Bachelor 17 Rehabilitation medicine N21 40 Female Married Master 21 General surgery N22 41 Female Married Bachelor 17 Thoracic Surgery N23 43 Female Married Bachelor 22 Hemodialysis An overarching theme ‘navigating the uncharted waters’ was identified from the analysis, reflecting the state of exploration,and adjustment in the unfamiliar and uncertain terrain of novice APNs. The following four themes were also identified:(1) being constrained by the practical environment; (2) reconstructing professional identity; (3) bearing multiple burdens; and (4) steering my own course(Fig. 1 ). 3.1 Theme 1: Being constrained by the practical environment Various environmental factors collectively shaped the professional development trajectory. In the practical environment, APNs were constrained by multiple limitations. 3.1.1 Lack of experience and guidance Most participants complained about the lack of available experience and mentor guidance due to the pioneering nature of the new role. “There is no template for us to follow in China owing to the lack of studies and experience. Therefore, we should learn from foreign models and internalize something.” (N11) “I feel lost, exploring on my own without sufficient support. In foreign countries, mentorship is prevalent, but as one of the first batches of APNs in China, I don’t have a mentor.” (N06) 3.1.2 Lack of organizational planning Healthcare institutions and departments lacked clear planning to support their development. For example, the uneven distribution of learning resources, unstable workforce structures, and mismatched salaries limited participants’ ability to realize their potential. “The institution doesn’t provide us with adequate resources, such as opportunities to attend academic conferences or participate in teaching and presentation activities.” (N06) “For various reasons, many young doctors have resigned from the department, creating a turbulent environment that complicates my work.” (N09) “With so much work pressure, my salary has not increased, which undermines my motivation.” (N10) 3.1.3 Lack of policy support and public recognition Almost all participants considered the lack of national policy support a significant barrier, as it meant that the role title was not legally protected. “Currently, my work is heavily restricted because there is no legislation for APNs in China (mainland), even in Sichuan Province. I feel like I don’t have the authority to direct others.” (N06) Additionally, they felt powerless because of the public’s limited awareness of APNs. “The employee badge of the APN is different from that of other nurses. Once, a patient asked, ‘Why does your badge look different? Are you from another hospital?’ This indicates that they aren’t familiar with the role of APNs.” (N15) 3.2 Theme 2: Reconstructing professional identity APNs highlighted dramatic changes in their identities, which seem to be from the inside out. 3.2.1 Obvious identity gap Most participants reported that the transition from an experienced registered nurse to an APN could be viewed as a shift from “expert - novice”, and this obvious identity gap made it difficult for them to adapt. “It’s like going from being an expert in one role to a novice in another. I’m thrust into an unknown world, with an inconspicuous identity.” (N10) “The APN is a completely new clinical role, and this transition to a new role and novice identity has left me feeling somewhat unsettled. I haven't adjusted yet.” (N08) Besides, ambitious aspirations were common among participants before formal practice, leading to a sense of gap. “After a long period of course learning, I felt ambitious. But then I didn’t make any progress in clinical practice. There is a gap between my expectations and my actual work performance. I have a bit of regret.” (N22) 3.2.2 Ambiguous professional positionality Several participants emphasized their awkward position in the clinical department, seemingly not belonging to any group. “We all feel that we are in an awkward position. What is an APN? The title is so prominent that it seems like we are at the top of the mountain, but in fact we are at the foot of the mountain.”(N18) “After becoming an APN, I was marginalized and felt like I didn’t belong to any group in the department. My position cannot be classified as administrative, as I possess no substantive managerial authority; nor does it fall under clinical nursing, since I am no longer responsible for specific patients…I'm just a bystander.”(N06) They also mentioned that unclear professional boundaries and responsibilities led role overlap. “The difference between my role and other roles is not obvious, so role overlap often occurs: the head nurse and I both manage critically ill patients, and the quality control nurse and I both oversee care quality. This has led to role conflict, as they feel I’ve overstepped the boundary and encroached on their authority.” (N09) 3.3 Theme 3: Bearing multiple burdens The new identity brought multiple burdens, including immense work pressure, disguised work tasks, and tense professional relationships. These factors imposed psychological and physical strain on them. 3.3.1 Work pressure and disguise Some participants expressed that the update of the work mode and the difficulty of implementing advanced nursing practices caused them significant stress. They even had to temporarily disguise themselves by taking on a large number of simple tasks to meet the department’s performance evaluation requirements. “I haven’t yet taken on the more challenging responsibilities expected of an APN, such as formulating some clinical standard procedures for the department or leading a multidisciplinary team to manage complex and critically ill patients. These advanced tasks are still very difficult for me at this stage. Therefore, I have to complete more basic tasks to disguise, such as evaluating interns and checking nursing records, which help me meet the workload requirements set by the department manager. ” (N14) One participant even described herself as an‘odd-job’ person. “I’m now an ‘odd-job’ person, filling in for others when needed. When the nursing group leader is on leave, I take her role. Sometimes, the head nurse assigns me a lot of clerical work: sort documents, make PowerPoints, attend meetings.......Although these tasks are not fully aligned with my professional role expectations, they contribute to creating an appearance of substantial workload.” (N08) 3.3.2 Tense professional relationships During the transition, the changes in professional relationships were not smooth and could even lead to work-related tension. Some participants reported that establishing a partnership with doctors was not an easy task. “When I find issues in clinical practice, I will alert doctors, but sometimes they don’t believe me, which makes me feel timid and hesitant.” (N02) Additionally, some participants felt isolated and lacked support and recognition from other nurses, as their work went beyond traditional nursing roles. “Some nurses gossip that ‘APNs don’t belong to clinical nursing groups, become ‘officials’, sit in ‘offices’, and work effortlessly.’ I’m not sure if this is out of jealousy, but it makes me feel sad and lost.” (N19) 3.3.3 Psychological and physical burden Most participants experienced many complex emotions. “A week ago, I tried to collaborate with surgical departments on blood sugar management for patients undergoing major abdominal surgeries, but it fell through. Now, I feel depressed and hopeless about the future.” (N09) “Previously, as a nursing group leader, I was responsible for the patients in my group only. Now, I should pay attention to all patients in the ward, which often leaves me feeling doubtful and unconfident.” (N10) These emotions not only created a heavy psychological burden but also had a detrimental impact on their physical health. “I have an emotional eating problem, tending to eat a lot when I’m feeling down, especially after work.” (N09) “In the first one or two weeks of being employed as APN, I often lost sleep.”(N19) 3.4 Theme 4: Steering my own course Despite encountering numerous difficulties, some APNs still realized their value to a certain extent through their efforts and persistence and gradually found role meaning. 3.4.1 Personal motivation and persistence The participants expressed their motivation for professional development. “When I solve clinical problems for patients, I feel a sense of fulfilment. This is also why I choose to be an APN - to immerse myself in clinical practice and develop my expertise.” (N08) They also emphasized the importance of personal perseverance in overcoming numerous challenges. “I believe that internal persistence is the most crucial element, as it drives one to respond proactively. When facing communication challenges, I seek the assistance of the head nurse to facilitate my communication with the doctor.” (N07) 3.4.2 Proactive learning Proactive learning was the most effective and feasible approach to adapting to the new role for most participants. They not only strengthened their expertise within their specialized fields but also actively expanded their knowledge and skills across disciplines to provide better care for patients with complex conditions. “I attended formal training to master the skills of ultrasound examinations. Now, in my department, doctors ask me to perform bedside ultrasound examinations for patients after kidney biopsy.” (N12) “I continue to expand my knowledge in multidisciplinary areas.”(N16) Several participants also highlighted the reason for proactive learning, as there was a gap between educational training and the demands of clinical practice. Purposeful, proactive and in-depth learning was required to achieve advanced nursing practice. “The APN training program focuses on critical thinking and methodology, teaching me how to systematically solve clinical problems. However, there remains a deficiency in specialty specific depth. When encountering complex patient cases in clinica, I find it necessary to pursue additional learning.”(N12) Additionally, learning-derived professional activities, such as organizing case discussions and sharing clinical experiences, can also facilitated their quicker integration into the department. “I regularly collect challenging patient cases from the ward and organize case discussions to achieve common progress.” (N08) 3.4.3 Desire for a graduate degree Most participants had high aspirations for both personal and professional development, with a postgraduate degree being regarded as a key factor in achieving these objectives. Two participants, who are currently pursuing a graduate degree, stated, "combining graduate studies with clinical work keeps me very busy, I am eager to obtain a graduate degree." (N7) In addition, several participants were actively preparing for postgraduate entrance examinations. "I devote more time to preparing for the graduate admission test and also attend training courses on weekends.' (N2) They expressed multiple motivations for pursuing postgraduate qualifications. "In many countries, the postgraduate degree is mandatory for APNs. Although this requirement has not yet been implemented in China, it represents a future trend. So I want to better align with the role title.”(N4) "In clinical settings, practitioners with higher educational qualifications are typically accorded greater professional authority, which is essential for advancing advanced nursing practice." (N9) "For promotion system in the hospital, a postgraduate degree is an indispensable prerequisite." (N5) 3.4.4 Role value Some participants found their role value, becoming the “glue” between multidisciplinary teams, the “warners” of patient risk, and the “instructor for clinical nurses”... “I communicate with respiratory therapists and dieticians, discuss the outcomes of these communications with doctors, and formulate relevant plans. The doctors often take my advice. Now I act as the ‘glue’ between them.” (N02) “After rescuing a patient, I would reflect on why the patient’s condition had changed and why such a treatment plan was adopted and consult relevant literature. Then, I communicate with the doctor to sort out the procedure for rescuing such patients, provide guidance to other nurses, and supervise them in following the procedure.” (N02) Meanwhile, although other participants had not yet achieved significant work outcomes, they still sensed their value through feedback from others. “I feel so proud when the doctor asks me something. As I received positive feedback.” (N02) 4. Discussion This study represents the first attempt to explore transition experiences for APNs in mainland China, with a specific focus on novices who had been in practice for less than one month. The core finding reveals that these APNs navigated uncharted waters of their new roles. Constrained by the complexities of an unfamiliar environment, they undertook efforts to reconstruct professional identities, managed multiple responsibilities, and actively steered their own courses through this transitional phase.This study enhances our understanding of the transition of novice APNs and provides valuable insights for optimizing educational models and developing transition programs. From a macro perspective, the practical environment refers to China’s political, cultural and social background. First, the lack of policy support is the greatest issue at present. Owing to the short history of developing APNs in mainland China, relevant health policies have not yet been introduced to define their rights and obligations, resulting in a lack of protection for the title. Concurrently, limited public awareness channels for APNs and the absence of official and authoritative information have led to low recognition. This finding has been confirmed in several studies in China[ 25 , 31 ]. It can be seen that at the policy level, a legal and regulatory framework that supports the development of advanced practice nursing is necessary. However, such systemic transformation can not be achieved overnight[ 32 ]. It requires a stepwise implementation of pilot programs to demonstrate the significance and value of APNs within China's healthcare system. Due to the pioneering nature of APNs in China, there is limited practical research and scarce experience. As the first exploratory qualitative study in this field in China, while focusing on APNs' individual experiences, this research has revealed their environmental challenges and provided preliminary evidence of their clinical contributions. These findings lay the groundwork for developing a standardized national system for APN training, certification, and regulation in China. From a micro perspective, the practical environment refers to institutions or departments where APNs work. We found that organizational characteristics, such as high staff turnover, a discordant atmosphere, and the inequitable treatment of APNs by the organization, such as mismatched incentives and unbalanced learning opportunities, significantly hindered the role transition of APNs. These contextual constraints contribute to more negative experiences.This phenomenon may be particularly pronounced in mainland China, where APNs are regulated at the institutional level, thereby amplifying the impact of work environment[ 33 ]. Our findings suggest that healthcare institutions, as the primary governing bodies of APN practice, should provide adequate support to maximize their professional potential. The transition in professional identity resulted in a sense of gap, which was not favourable in the early stage. Shifting from “expert” to “novice,” from “familiar” to “unknown,” APNs felt that they had returned to the starting point of their career[ 34 ], facing even more severe challenges than novice registered nurses with no prior knowledge, due to the unclear boundaries and responsibilities of their professional roles. These findings are consistent with those of previous studies[ 8 , 35 ]. “Bystander”, “awkward”, “marginalized”, and “odd-job” were their descriptions of themselves, as their role had not yet been differentiated from other clinical roles. They found themselves caught between multiple responsibilities, leading to role overlap and potential role conflict. This ambiguous professional positionality exacerbated tensions within the workplace, such as scepticism from physicians and isolation from their nursing colleagues[ 36 ]. Compared with previous studies[ 9 , 37 ], the process of professional identity reconstruction in this study seems to be even more demanding. This may be due to our participants' limited tenure (less than one month), which enabled them to provide more profound insights into the challenges encountered during the initial transition phase. Participants in previous studies had generally completed their role transition, and their reflections tended to focus on the overall role changes[ 38 ]. Our finding is consistent with other studies showing that APNs bear multiple burdens[ 39 ]. However, the sources of these burdens differ from those identified in previous studies[ 18 , 34 ]. APNs find it challenging to dedicate time during work hours for deep thinking and planning because they do not want to be misinterpreted as “idle” by other nurses and instead have to “disguise” themselves with multifarious workloads. This is also related to tense work relationships. Faced with doubts from colleagues, they lack the confidence to take on challenging tasks and tend to choose more basic and error-free tasks. This kind of “disguise” seems to be a unique manifestation among APNs in China, which may conceal their talents. As repeatedly mentioned in previous studies, negative emotions, including “anxious”, “frustrated”, “depressed”, and “annoyed”, occur frequently in APNs[ 40 , 41 ]. Insomnia and emotional eating are unique findings in this study, further highlighting the challenges and frustrations faced by APNs, particularly those with short employment durations. These findings suggest that support strategies are urgently needed. Proactive learning is currently the simplest and most effective coping strategy available to APNs, particularly in acquiring interdisciplinary knowledge and skills. This may be related to the current core professional positioning of Chinese APNs - solving complex multidisciplinary clinical problems. In countries such as the United States, The United Kingdom, and Singapore, the educational system for nurse prescribing is well-developed[ 42 ], with prescriptive authority established as a hallmark function of APNs[ 43 ]. However, in mainland China, there is a cautious attitude towards nurse prescribing[ 44 ], and most APNs are not yet able to regard prescription decision-making as a career breakthrough[ 45 ]. Instead, they tend to focus on complex case management and multidisciplinary collaboration, thus forming a unique professional advantage. Therefore, the education of APNs should not be limited to cognitive development and theoretical methodologies but should also incorporate clinical interdisciplinary modules[ 46 ]. For practicing APNs, it is essential to provide multidisciplinary communication platforms and support resources, such as interdisciplinary case discussions, peer support systems, and mentorship programs. A master’s degree is recommended for entry level by International Council of Nurses (ICN)[ 1 ]. And this criterion has been widely adopted in countries with well-established advanced practice nursing systems, such as the United States, United Kingdom, and Canada[ 47 ]. The guideline published by ICN also indicates that the characteristics of APNs are shaped by the context in which they are credentialed to practice. For example, a review of APNs in Low- and lower middle-income countries revealed that the type of education ranged from continuing education and non-accredited post-registration diploma to masters[ 3 ]. Therefore, viable approaches for developing and implementing new APN role must be grounded in each country's specific healthcare system and nursing workforce[ 48 , 49 ]. Currently in China, only 0.2% of nurses hold graduate degrees[ 50 ], which presents significant challenges in directly applying the international master's degree standard. Therefore, selecting experienced bachelor's-degree nurses as potential APN candidates is a feasible strategy during the initial phase of role implementation[ 22 ]. Although not all APNs currently hold master's degrees, this study reveals a strong aspiration for graduate education among them. This phenomenon can be attributed to multiple factors: higher educational qualification can enhances professional confidence and authority, fosters recognition within interdisciplinary teams, and increases probability of professional title advancement - collectively leading to better alignment with APN role expectations. This creates a virtuous cycle of "education- APN role": the APN role motivates nurses to pursue higher education, while the attainment of higher education further enhances role congruence. These findings substantiate the positive impact of APN role implementation on the professional development of nursing. 4.1 Strengths and limitations This is the first study to explore the transition experience of novice APNs within mainland China, offering some perspectives that differ from those of previous research conducted primarily in Western countries. In addition, including participants of different genders, ages, educational backgrounds, and departments contributes to the richness of the research data. However, there are several limitations in this study. An interview is a form of self-report, which may involve recall bias[ 51 ]. Therefore, we selected APNs who had been employed for less than a month to minimize recall bias and directly revealed the conflicts and issues encountered during the early transition period. Moreover, this study was conducted in a city, so the generalizability of our findings may be limited. However, this is due to the small number of APNs in China, and it is also designed to achieve face-to-face and in-depth interviews to obtain the information conveyed by facial expressions and body language. 5. Conclusion This study makes novice APNs' roles and experiences more transparent. Being constrained by the practical environment, reconstructing professional identity, and bearing multiple burdens were identified as three main themes, which illustrated a grim picture of the APNs' experiences. However, despite the tumultuous initial phase of transitioning into a new role, they steered their own course, with some even realizing their professional value. Additionally, we observed unique characteristics among APNs in China, including "disguise" in their work and a strong desire for a graduate degree. Future research should further explore APNs' stage experiences and provide a theoretical basis for optimizing educational models and developing targeted support programs. Declarations Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of West China Hospital of Sichuan University (20231992). The participants were informed that they could voluntarily decide whether to participate in the study and withdraw at any time without penalty. Informed consent was obtained from all participants. Participant confidentiality was ensured by using special codes ranging from N1 to N23. In addition, only the researchers had access to the data. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests。 Funding None. Author Contribution TW and JY conceptualized this study. TW conducted the interviews. TW and HQ analyzed the data. LSS, WC, WL and JY provided regular feedback during data analysis. TW wrote the first draft and substantial contributions and revisions were made by HQ, LSS, WC, WL and JY. All authors read and approved the final manuscript. Acknowledgement We express our gratitude to the advanced practice nurses who took part in this study and shared their experiences. Data Availability The dataset and analysis supporting the conclusions of this article is available under request to the corresponding author. References International Council of Nurses,. 2020. Guidelines on Advanced Practice Nursing 2020. https://www.icn.ch/sites/default/files/2023-04/ICN_APN%20Report_EN.pdf Xu C, Koh KWL, Zhou W. The development of advanced practice nurses in Singapore. Int Nurs Rev. 2024;71(2):238–43. http://doi.org/10.1111/inr.12810 . Scanlon A, Murphy M, Smolowitz J, Lewis V. Low- and lower middle-income countries advanced practice nurses: an integrative review. Int Nurs Rev. 2020;67(1):19–34. http://doi.org/10.1111/inr.12536 . World Health Organization. 2020. State of the world's nursing 2020: investing in education, jobs, and leadership. https://apps.who.int/iris/handle/10665/331677 McMenamin A, Turi E, Schlak A, Poghosyan L. A Systematic Review of Outcomes Related to Nurse Practitioner-Delivered Primary Care for Multiple Chronic Conditions. 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Driven by Ambitions: The Nurse Practitioner's Role Transition in Dutch Hospital Care. J Nurs Scholarsh. 2015;47(6):544–54. http://doi.org/10.1111/jnu.12164 . Guo H, Zhu W, Li J. Developing a core competency framework for advanced practice nursing in mainland China: a sequential exploratory study. BMC Nurs. 2023;22(1):179. http://doi.org/10.1186/s12912-023-01335-4 . Wong FKY. Development of advanced nursing practice in China: Act local and think global. Int J Nurs Sci. 2018;5(2):101–4. http://doi.org/10.1016/j.ijnss.2018.03.003 . Zhan Q, Shang S, Li W, Chen L. Bridging the GP gap: nurse practitioners in China. Lancet. 2019;394(10204):1125–7. http://doi.org/10.1016/s0140-6736(19)32209-3 . Liu YW, Hei LX, Gong RR, Ning N, Jiang Y. Reflection on the way of selecting and training of advanced practice nurse candidates. Chin J Nurs Educ. 2023;20(09):1147–52. http://doi.org/10.3761/j.issn.1672-9234.2023.09.021 . Zhao WJ, Xia HO. A qualitative study on the work experience of ICU advanced practice nurse. J Nurs Sci. 2014;29(08):71–4. https://doi.org/10.3870/hlxzz.2014.08.071 . Zhang WQ, Tang W, Hu FH, Jia YJ, Ge MW, Zhao DY, Shen WQ, Zha ML, Chen HL. Impact of the National Nursing Development Plan on nursing human resources in China: An interrupted time series analysis for 1978–2021. Int J Nurs Stud. 2023;148:104612. http://doi.org/10.1016/j.ijnurstu.2023.104612 . Hou SN, Guo YX, Ma Q, Yang J, Ni W. A survey on the influencing factors of common residents' cognition and trust towards nurse practitioner in China. J Nurs Train. 2021;36(7):668–71. http://doi.org/10.16821/j.cnki.hsjx.2021.07.022 . Sandelowski M. What's in a name? Qualitative description revisited. Res Nurs Health. 2010;33(1):77–84. http://doi.org/10.1002/nur.20362 . Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. http://doi.org/10.1093/intqhc/mzm042 . Gong Renrong H, Lingxiao C, Jiali Z, Xuhua, Jiang Y. Construction of core competence framework for Advanced Practice Nurse. Chin Nurs Manage. 2023;23(5):654–9. http://doi.org/10.3969/j.issn.1672-1756.2023.05.004 . Braun V, Clarke VJQrip. 2006. Using thematic analysis in psychology. 3 (2), 77–101. Johnson JL, Adkins D, Chauvin S. A Review of the Quality Indicators of Rigor in Qualitative Research. Am J Pharm Educ. 2020;84(1):7120. http://doi.org/10.5688/ajpe7120 . Hu ZY, Gong RR, Liu YW, Gou FW. A Survey on the Cognition and Attitudes of 684 Surgical Nurses towards the Role of Advanced Practice Nurses. J Nurs. 2020;27(16):44–8. http://doi.org/10.16460/j.issn1008-9969.2020.16.044 . Cantón-Rodríguez Y, Ibáñez-Masero O, García-Navarro EB, Ortega-Galán Á, Ventura-Miranda M, Ruiz-Fernández MI, M.D. Professional experiences of spanish advanced practice nurses: qualitative research. BMC Nurs. 2024;23(1):439. http://doi.org/10.1186/s12912-024-02105-6 . Chun CK, Wong FK, Wang SL, Chen W. Examining advanced nursing practice in Hong Kong and Guangzhou. Int J Nurs Sci. 2021;8(2):190–8. http://doi.org/10.1016/j.ijnss.2021.03.001 . Jangland E, Yngman Uhlin P, Arakelian E. Between two roles - Experiences of newly trained nurse practitioners in surgical care in Sweden: A qualitative study using repeated interviews. Nurse Educ Pract. 2016;21:93–9. http://doi.org/10.1016/j.nepr.2016.10.005 . Faraz A. Facilitators and barriers to the novice nurse practitioner workforce transition in primary care. J Am Assoc Nurse Pract. 2019;31(6):364–70. http://doi.org/10.1097/jxx.0000000000000158 . Torrens C, Campbell P, Hoskins G, Strachan H, Wells M, Cunningham M, Bottone H, Polson R, Maxwell M. Barriers and facilitators to the implementation of the advanced nurse practitioner role in primary care settings: A scoping review. Int J Nurs Stud. 2020;104:103443. http://doi.org/10.1016/j.ijnurstu.2019.103443 . Graham D. Novice Nurse Practitioners’ Perceptions of Role Transition. Western Connecticut State University; 2020. Serra-Barril MA, Ferro-Garcia T, Fernandez-Ortega P, Sanchez-Lopez C, Martinez-Momblan MA, Benito-Aracil L, Romero-Garcia M. The role experience of advanced practice nurses in oncology: An interpretative phenomenological study. J Adv Nurs. 2024;80(6):2512–24. http://doi.org/10.1111/jan.15997 . van Kraaij J, van Oostveen C, Vermeulen H, Heinen M, Huis A, Adriaansen M, Peters J. Nurse practitioners' perceptions of their ability to enact leadership in hospital care. J Clin Nurs. 2020;29(3–4):447–58. http://doi.org/10.1111/jocn.15105 . Hill LA, Sawatzky JA. Transitioning into the nurse practitioner role through mentorship. J Prof Nurs. 2011;27(3):161–7. http://doi.org/10.1016/j.profnurs.2011.02.004 . Pleshkan V, Hussey L. Nurse practitioners' experiences with role transition: Supporting the learning curve through preceptorship. Nurse Educ Pract. 2020;42:102655. http://doi.org/10.1016/j.nepr.2019.102655 . Tan W, Hu Q, Wang C, Li Y, Jiang Y. Outline of nurse prescribing education programs: A scoping review. Nurse Educ Today. 2023;131:105941. http://doi.org/10.1016/j.nedt.2023.105941 . Grundy Q, Held F, Hart D, Baugh CM, Ladd E, Campbell E, Bero L. Characteristics of Advanced Practice Nurses Receiving Top Industry Payments and Their Practice Settings: a Cross-sectional Study. J Gen Intern Med. 2024;39(7):1142–8. http://doi.org/10.1007/s11606-023-08508-6 . Wang X, Wu Y, Bai X, Wang Y, Wang J, Zang S. Understanding Chinese adults' attitudes toward nurse prescribing: A national cross-sectional study. Int J Nurs Stud. 2025;166:105064. http://doi.org/10.1016/j.ijnurstu.2025.105064 . Zhang Q, Han S, Dong W, Cao G, Wang Z, Li M, Zhu R. Barriers and facilitators to the application of nurse practitioners' training pilot programs in China: A CFIR-guided descriptive qualitative study. Nurse Educ Today. 2025;145:106501. http://doi.org/10.1016/j.nedt.2024.106501 . Zhou W, Poh CL, Chan HL, Shorey S. Development of entrustable professional activities for advanced practice nurses education. Nurse Educ Today. 2022;116:105462. http://doi.org/10.1016/j.nedt.2022.105462 . Wheeler KJ, Miller M, Pulcini J, Gray D, Ladd E, Rayens MK. Advanced Practice Nursing Roles, Regulation, Education, and Practice: A Global Study. Ann Glob Health. 2022;88(1):42. http://doi.org/10.5334/aogh.3698 . Almukhaini S, Weeks LE, Macdonald M, Martin-Misener R, Ismaili ZA, Macdonald D, Al-Fahdi N, Rasbi SA, Nasaif H, Rothfus MA. Advanced practice nursing roles in Arab countries in the Eastern Mediterranean region: a scoping review. JBI Evid Synth. 2022;20(5):1209–42. http://doi.org/10.11124/jbies-21-00101 . Moafa H, Almotairy MM, Nahari A, Alhamed A, Aboshaiqah AE, Hakamy E, Qaladi O. Lessons learned from Saudi nurse academic leaders about advanced practice nursing roles: a qualitative approach. BMC Nurs. 2025;24(1):224. http://doi.org/10.1186/s12912-025-02871-x . National Health Commission of the People's Republic of China,. 2023. 2022 China Health Statistics Yearbook. https://www.nhc.gov.cn/mohwsbwstjxxzx/tjtjnj/202305/49beded3bd984669bfe9089c6f231cf5/files/1740022550235_90098.pdf . Khare SR, Vedel IJFP. 2019. Recall bias and reduction measures: an example in primary health care service utilization. 36 (5), 672–6. https://doi.org/10.1093/fampra/cmz042 Additional Declarations No competing interests reported. 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12:38:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8879966/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8879966/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12912-026-04626-8","type":"published","date":"2026-04-06T15:59:07+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":103599669,"identity":"873e761e-00a7-48e2-ac70-314aa84959f4","added_by":"auto","created_at":"2026-02-27 13:51:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":466089,"visible":true,"origin":"","legend":"\u003cp\u003eOverview of themes and sub-themes.\u003c/p\u003e","description":"","filename":"Figures.png","url":"https://assets-eu.researchsquare.com/files/rs-8879966/v1/2731469443eaaba3cdf885be.png"},{"id":106810259,"identity":"e46a845e-6410-4851-bb67-3332df5a38d3","added_by":"auto","created_at":"2026-04-13 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Introduction","content":"\u003cp\u003eThe International Council of Nurses defines an advanced practice nurse(APN) as \u0026ldquo;a generalist or specialized nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for advanced nursing practice\u0026rdquo;[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. To address the dual challenges of the continuous increase in healthcare demands and the ongoing shortage of healthcare professionals, the development of APNs has exhibited a global trend[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Currently, approximately 70 countries or regions have introduced APNs[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and are at different stages of developing advanced practice nursing[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The value of APNs has been widely demonstrated. The evidence is substantial that APNs contribute to providing high-quality healthcare services[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], improving patient clinical outcomes and satisfaction[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], and reducing medical costs[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe development and implementation of new roles is never an easy task, and the transitional phase is particularly crucial[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. For APNs newly entering the workforce, the transition to this new role is a dynamically changing and multi-challenging process, requiring them to master new knowledge and skills, shoulder new responsibilities, establish new professional relationships, and integrate into new practice areas[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Multiple international studies have shown that novice APNs encounter difficulties and obstacles, including low personal confidence, a lack of recognition from other healthcare professionals, and heavy work burdens[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These difficulties often lead to adverse consequences, such as negative emotions, low job satisfaction, job burnout, and even increased intention to leave[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. It is evident that the transition to APNs is problematic[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. A comprehensive understanding of the transition and looking at changes in transition can provide deeper insights into the \u0026ldquo;fuzzy logic of practice\u0026rdquo;, which is very helpful for facilitating the transition[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. For example, a study constructed a theoretical model \u0026ldquo;from Limbo to Legitimacy\u0026rdquo; through qualitative interviews, describing common practice experiences in the transition to the primary care nurse practitioner role[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. On the basis of this common experience, scholars subsequently organized targeted webinars, which were shown to positively influence the NP\u0026rsquo;s perceptions of role transition[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Therefore, deeply exploring the transition experience and developing corresponding intervention strategies can make the transition smoother.\u003c/p\u003e \u003cp\u003eInternationally, given the importance of the transition experience, many scholars have conducted a series of studies on this topic, identifying some common phenomena and analysing related obstacles and promoting factors[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, many participants in these studies have held the role of APNs for a long time, almost more than 1 year[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. For example, a qualitative study of nurse practitioners who have been working in the Netherlands for 2 to 6 years revealed that they have achieved success and that role transition is driven by ambitions[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Existing research has primarily focused on their post-transition experiences and professional growth, while paying less attention to the transition process between old and new roles\u0026mdash;particularly their initial clinical experiences after completing educational training programs. This may be attributed to the long recall period of the participants, as some of their early feelings may have faded from memory.\u003c/p\u003e \u003cp\u003eAs an innovative role that expands the boundaries of traditional nursing practice, the development of APNs in mainland China is still in the nascent stage. In the early 21st century, scholars began to explore this topic, but their discussions were limited to theoretical research, focusing on translating and analysing foreign concepts. Since 2010, the education and training of APNs, such as curriculum design, training objectives, and core competencies, has become a research hotspot[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Subsequently, several medical schools and healthcare institutions initiated pilot education programs[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In 2017, the Peking University School of Nursing enrolled students in the Nurse Practitioner Master's program in Chronic Disease Management[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In 2021, the West China Hospital of Sichuan University launched an in-service training program for APNs[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, few practical studies exist, and few scholars have focused on the experiences and performance of APNs after they enter the workforce. Only one study has described the work experiences of APNs in the ICU, finding that they have unclear professional positionality and are prone to role conflicts[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. There may be a disconnect between education and actual clinical practice, highlighting the need for further practical exploration to optimize training content and develop effective transition programs.\u003c/p\u003e \u003cp\u003eAdditionally, China\u0026rsquo;s social culture, healthcare system, and health service needs differ from those of other countries. There are also differences in nurses' social status, educational background, and staffing levels[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Although the Chinese Nursing Association has proposed starting an APN program, APNs have not yet been protected by law, and public awareness of their role is limited[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Therefore, APNs in mainland China follow a localized model, and their experiences may differ from those in other countries. Moreover, no Chinese scholars have yet researched the transition to APNs, making the exploration of this field even more urgent in mainland China.\u003c/p\u003e \u003cp\u003eTherefore, this study aims to investigate the transition experiences of novice APNs in China and provide insights for developing educational programs and intervention strategies to support smooth transition.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design\u003c/h2\u003e \u003cp\u003eA descriptive qualitative design was used. This method helps to obtain comprehensive and direct descriptions of participants' experiences[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The reporting of this study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] (Related File 1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Setting and participants\u003c/h2\u003e \u003cp\u003ePurposive sampling was employed to recruit participants from two tertiary hospitals in mainland China. The inclusion criteria were: (1) completing the APN training curriculum;(2) being employed as an APN; and (3) assuming APN responsibilities for less than 1 month.\u003c/p\u003e \u003cp\u003eGiven the early developmental stage of the APN role in China and the absence of a unified national regulatory framework, training and certification are currently led by various entities, including professional nursing associations, academic institutions, and hospitals, resulting in considerable variability in standards. This first exploratory study on APNs in mainland China seeks to provide foundational evidence to clarify the role.\u003c/p\u003e \u003cp\u003eThe APN training program referenced in this study was based on a nationally developed core competency framework encompassing six domains: clinical care, consultation, coordination, leadership, teaching, and research[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The resulting curriculum comprised 36 modules (12 hours each). Certification required passing both theoretical assessments and an Objective Structured Clinical Examination (OSCE), administered by the participating hospitals.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data collection\u003c/h2\u003e \u003cp\u003eA semi-structured interview guide was developed based on literature review, team discussions, and a pilot test with two participants (Supplementary File 1). Between September and December 2023, the first author conducted individual face-to-face interviews in a quiet hospital conference room, encouraging participants to freely share their experiences. Each interview was audio-recorded in Chinese, and field notes about participants' facial expressions and body language as well as the interviewer's reflections were compiled. Data saturation was achieved after the 21st interview, as no new information emerged. Two additional interviews were conducted to confirm saturation, resulting in a final sample of 23 participants. Interviews lasted 31 to 103 minutes (mean: 64 minutes).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data analysis\u003c/h2\u003e \u003cp\u003eBraun \u0026amp; Clarke\u0026rsquo;s thematic analysis method was used, following six phases: familiarising yourself with your data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Two authors read and reread the data for coding and then collated the codes into potential themes and subthemes. By holding regular team meetings, these themes were discussed and refined until a consensus was reached. Data were analyzed using NVivo 12.0.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Rigor\u003c/h2\u003e \u003cp\u003eThe rigor includes four dimensions: credibility, transferability, dependability and confirmability [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. All the interviews were conducted by the same author to maintain consistency and ensure data credibility. She is a PhD student in nursing with research experience in advanced nursing practice and qualitative studies, has a strong interest in the topic, and does not have any apparent biases or professional relationships with the participants. In addition, all interviews were audio-recorded and transcribed systematically to ensure credibility. A comprehensive presentation of the context, participants, and data collection and analysis procedures and a detailed description of the findings were provided to establish transferability. Dependability was ensured by using field notes and sharing transcribed data and preliminary analysis results with the participants. Two authors separately coded the transcription data and held regular meetings with other team members, further increasing the confirmability of the data.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eTwenty-three participants aged between 32 and 50 years participated in this study. The majority of the participants were female (n\u0026thinsp;=\u0026thinsp;21), and held a bachelor's degree (n\u0026thinsp;=\u0026thinsp;18). The demographic characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of the participants (n\u0026thinsp;=\u0026thinsp;23).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLevel of Education\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNursing tenure (Years\u0026nbsp;)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePractice area\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEndoscopy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUrology\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMaster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEndocrinology\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGeratology\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGeneral surgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGeratology\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBiological therapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOrthopedics\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMaster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEndocrinology\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGastroenterology\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGeratology\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMaster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNephrology\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThoracic Oncology\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMaster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGeneral surgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCardiovascular Surgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGeneral surgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEndoscopy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRehabilitation medicine\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLung cancer\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRehabilitation medicine\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMaster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGeneral surgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThoracic Surgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHemodialysis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAn overarching theme \u0026lsquo;navigating the\u0026ensp;uncharted waters\u0026rsquo; was identified from the analysis, reflecting the state of exploration,and adjustment in the unfamiliar and uncertain terrain of novice APNs. The following four themes were also identified:(1) being constrained by the practical environment; (2) reconstructing professional identity; (3) bearing multiple burdens; and (4) steering my own course(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Theme 1: Being constrained by the practical environment\u003c/h2\u003e \u003cp\u003eVarious environmental factors collectively shaped the professional development trajectory. In the practical environment, APNs were constrained by multiple limitations.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e3.1.1 Lack of experience and guidance\u003c/h2\u003e \u003cp\u003eMost participants complained about the lack of available experience and mentor guidance due to the pioneering nature of the new role.\u003c/p\u003e \u003cp\u003e\u0026ldquo;There is no template for us to follow in China owing to the lack of studies and experience. Therefore, we should learn from foreign models and internalize something.\u0026rdquo; (N11)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I feel lost, exploring on my own without sufficient support. In foreign countries, mentorship is prevalent, but as one of the first batches of APNs in China, I don\u0026rsquo;t have a mentor.\u0026rdquo; (N06)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e3.1.2 Lack of organizational planning\u003c/h2\u003e \u003cp\u003eHealthcare institutions and departments lacked clear planning to support their development. For example, the uneven distribution of learning resources, unstable workforce structures, and mismatched salaries limited participants\u0026rsquo; ability to realize their potential.\u003c/p\u003e \u003cp\u003e\u0026ldquo;The institution doesn\u0026rsquo;t provide us with adequate resources, such as opportunities to attend academic conferences or participate in teaching and presentation activities.\u0026rdquo; (N06)\u003c/p\u003e \u003cp\u003e\u0026ldquo;For various reasons, many young doctors have resigned from the department, creating a turbulent environment that complicates my work.\u0026rdquo; (N09)\u003c/p\u003e \u003cp\u003e\u0026ldquo;With so much work pressure, my salary has not increased, which undermines my motivation.\u0026rdquo; (N10)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e3.1.3 Lack of policy support and public recognition\u003c/h2\u003e \u003cp\u003eAlmost all participants considered the lack of national policy support a significant barrier, as it meant that the role title was not legally protected.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Currently, my work is heavily restricted because there is no legislation for APNs in China (mainland), even in Sichuan Province. I feel like I don\u0026rsquo;t have the authority to direct others.\u0026rdquo; (N06)\u003c/p\u003e \u003cp\u003eAdditionally, they felt powerless because of the public\u0026rsquo;s limited awareness of APNs.\u003c/p\u003e \u003cp\u003e\u0026ldquo;The employee badge of the APN is different from that of other nurses. Once, a patient asked, \u0026lsquo;Why does your badge look different? Are you from another hospital?\u0026rsquo; This indicates that they aren\u0026rsquo;t familiar with the role of APNs.\u0026rdquo; (N15)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Theme 2: Reconstructing professional identity\u003c/h2\u003e \u003cp\u003eAPNs highlighted dramatic changes in their identities, which seem to be from the inside out.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 Obvious identity gap\u003c/h2\u003e \u003cp\u003eMost participants reported that the transition from an experienced registered nurse to an APN could be viewed as a shift from \u0026ldquo;expert - novice\u0026rdquo;, and this obvious identity gap made it difficult for them to adapt.\u003c/p\u003e \u003cp\u003e\u0026ldquo;It\u0026rsquo;s like going from being an expert in one role to a novice in another. I\u0026rsquo;m thrust into an unknown world, with an inconspicuous identity.\u0026rdquo; (N10)\u003c/p\u003e \u003cp\u003e\u0026ldquo;The APN is a completely new clinical role, and this transition to a new role and novice identity has left me feeling somewhat unsettled. I haven't adjusted yet.\u0026rdquo; (N08)\u003c/p\u003e \u003cp\u003eBesides, ambitious aspirations were common among participants before formal practice, leading to a sense of gap.\u003c/p\u003e \u003cp\u003e\u0026ldquo;After a long period of course learning, I felt ambitious. But then I didn\u0026rsquo;t make any progress in clinical practice. There is a gap between my expectations and my actual work performance. I have a bit of regret.\u0026rdquo; (N22)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2 Ambiguous professional positionality\u003c/h2\u003e \u003cp\u003e Several participants emphasized their awkward position in the clinical department, seemingly not belonging to any group.\u003c/p\u003e \u003cp\u003e\u0026ldquo;We all feel that we are in an awkward position. What is an APN? The title is so prominent that it seems like we are at the top of the mountain, but in fact we are at the foot of the mountain.\u0026rdquo;(N18)\u003c/p\u003e \u003cp\u003e\u0026ldquo;After becoming an APN, I was marginalized and felt like I didn\u0026rsquo;t belong to any group in the department. My position cannot be classified as administrative, as I possess no substantive managerial authority; nor does it fall under clinical nursing, since I am no longer responsible for specific patients\u0026hellip;I'm just a bystander.\u0026rdquo;(N06)\u003c/p\u003e \u003cp\u003eThey also mentioned that unclear professional boundaries and responsibilities led role overlap.\u003c/p\u003e \u003cp\u003e\u0026ldquo;The difference between my role and other roles is not obvious, so role overlap often occurs: the head nurse and I both manage critically ill patients, and the quality control nurse and I both oversee care quality. This has led to role conflict, as they feel I\u0026rsquo;ve overstepped the boundary and encroached on their authority.\u0026rdquo; (N09)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Theme 3: Bearing multiple burdens\u003c/h2\u003e \u003cp\u003eThe new identity brought multiple burdens, including immense work pressure, disguised work tasks, and tense professional relationships. These factors imposed psychological and physical strain on them.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1 Work pressure and disguise\u003c/h2\u003e \u003cp\u003eSome participants expressed that the update of the work mode and the difficulty of implementing advanced nursing practices caused them significant stress. They even had to temporarily disguise themselves by taking on a large number of simple tasks to meet the department\u0026rsquo;s performance evaluation requirements.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I haven\u0026rsquo;t yet taken on the more challenging responsibilities expected of an APN, such as formulating some clinical standard procedures for the department or leading a multidisciplinary team to manage complex and critically ill patients. These advanced tasks are still very difficult for me at this stage. Therefore, I have to complete more basic tasks to disguise, such as evaluating interns and checking nursing records, which help me meet the workload requirements set by the department manager. \u0026rdquo; (N14)\u003c/p\u003e \u003cp\u003eOne participant even described herself as an\u0026lsquo;odd-job\u0026rsquo; person.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I\u0026rsquo;m now an \u0026lsquo;odd-job\u0026rsquo; person, filling in for others when needed. When the nursing group leader is on leave, I take her role. Sometimes, the head nurse assigns me a lot of clerical work: sort documents, make PowerPoints, attend meetings.......Although these tasks are not fully aligned with my professional role expectations, they contribute to creating an appearance of substantial workload.\u0026rdquo; (N08)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2 Tense professional relationships\u003c/h2\u003e \u003cp\u003eDuring the transition, the changes in professional relationships were not smooth and could even lead to work-related tension. Some participants reported that establishing a partnership with doctors was not an easy task.\u003c/p\u003e \u003cp\u003e\u0026ldquo;When I find issues in clinical practice, I will alert doctors, but sometimes they don\u0026rsquo;t believe me, which makes me feel timid and hesitant.\u0026rdquo; (N02)\u003c/p\u003e \u003cp\u003eAdditionally, some participants felt isolated and lacked support and recognition from other nurses, as their work went beyond traditional nursing roles.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Some nurses gossip that \u0026lsquo;APNs don\u0026rsquo;t belong to clinical nursing groups, become \u0026lsquo;officials\u0026rsquo;, sit in \u0026lsquo;offices\u0026rsquo;, and work effortlessly.\u0026rsquo; I\u0026rsquo;m not sure if this is out of jealousy, but it makes me feel sad and lost.\u0026rdquo; (N19)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e3.3.3 Psychological and physical burden\u003c/h2\u003e \u003cp\u003eMost participants experienced many complex emotions.\u003c/p\u003e \u003cp\u003e\u0026ldquo;A week ago, I tried to collaborate with surgical departments on blood sugar management for patients undergoing major abdominal surgeries, but it fell through. Now, I feel depressed and hopeless about the future.\u0026rdquo; (N09)\u003c/p\u003e \u003cp\u003e\u0026ldquo;Previously, as a nursing group leader, I was responsible for the patients in my group only. Now, I should pay attention to all patients in the ward, which often leaves me feeling doubtful and unconfident.\u0026rdquo; (N10)\u003c/p\u003e \u003cp\u003eThese emotions not only created a heavy psychological burden but also had a detrimental impact on their physical health.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I have an emotional eating problem, tending to eat a lot when I\u0026rsquo;m feeling down, especially after work.\u0026rdquo; (N09)\u003c/p\u003e \u003cp\u003e\u0026ldquo;In the first one or two weeks of being employed as APN, I often lost sleep.\u0026rdquo;(N19)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Theme 4: Steering my own course\u003c/h2\u003e \u003cp\u003eDespite encountering numerous difficulties, some APNs still realized their value to a certain extent through their efforts and persistence and gradually found role meaning.\u003c/p\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003e3.4.1 Personal motivation and persistence\u003c/h2\u003e \u003cp\u003e The participants expressed their motivation for professional development.\u003c/p\u003e \u003cp\u003e\u0026ldquo;When I solve clinical problems for patients, I feel a sense of fulfilment. This is also why I choose to be an APN - to immerse myself in clinical practice and develop my expertise.\u0026rdquo; (N08)\u003c/p\u003e \u003cp\u003eThey also emphasized the importance of personal perseverance in overcoming numerous challenges.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I believe that internal persistence is the most crucial element, as it drives one to respond proactively. When facing communication challenges, I seek the assistance of the head nurse to facilitate my communication with the doctor.\u0026rdquo; (N07)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003e3.4.2 Proactive learning\u003c/h2\u003e \u003cp\u003eProactive learning was the most effective and feasible approach to adapting to the new role for most participants. They not only strengthened their expertise within their specialized fields but also actively expanded their knowledge and skills across disciplines to provide better care for patients with complex conditions.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I attended formal training to master the skills of ultrasound examinations. Now, in my department, doctors ask me to perform bedside ultrasound examinations for patients after kidney biopsy.\u0026rdquo; (N12)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I continue to expand my knowledge in multidisciplinary areas.\u0026rdquo;(N16)\u003c/p\u003e \u003cp\u003eSeveral participants also highlighted the reason for proactive learning, as there was a gap between educational training and the demands of clinical practice. Purposeful, proactive and in-depth learning was required to achieve advanced nursing practice.\u003c/p\u003e \u003cp\u003e\u0026ldquo;The APN training program focuses on critical thinking and methodology, teaching me how to systematically solve clinical problems. However, there remains a deficiency in specialty specific depth. When encountering complex patient cases in clinica, I find it necessary to pursue additional learning.\u0026rdquo;(N12)\u003c/p\u003e \u003cp\u003eAdditionally, learning-derived professional activities, such as organizing case discussions and sharing clinical experiences, can also facilitated their quicker integration into the department.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I regularly collect challenging patient cases from the ward and organize case discussions to achieve common progress.\u0026rdquo; (N08)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003e3.4.3 Desire for a graduate degree\u003c/h2\u003e \u003cp\u003eMost participants had high aspirations for both personal and professional development, with a postgraduate degree being regarded as a key factor in achieving these objectives.\u003c/p\u003e \u003cp\u003eTwo participants, who are currently pursuing a graduate degree, stated, \"combining graduate studies with clinical work keeps me very busy, I am eager to obtain a graduate degree.\" (N7)\u003c/p\u003e \u003cp\u003eIn addition, several participants were actively preparing for postgraduate entrance examinations.\u003c/p\u003e \u003cp\u003e\"I devote more time to preparing for the graduate admission test and also attend training courses on weekends.' (N2)\u003c/p\u003e \u003cp\u003eThey expressed multiple motivations for pursuing postgraduate qualifications.\u003c/p\u003e \u003cp\u003e\"In many countries, the postgraduate degree is mandatory for APNs. Although this requirement has not yet been implemented in China, it represents a future trend. So I want to better align with the role title.\u0026rdquo;(N4)\u003c/p\u003e \u003cp\u003e\"In clinical settings, practitioners with higher educational qualifications are typically accorded greater professional authority, which is essential for advancing advanced nursing practice.\" (N9)\u003c/p\u003e \u003cp\u003e\"For promotion system in the hospital, a postgraduate degree is an indispensable prerequisite.\" (N5)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section3\"\u003e \u003ch2\u003e3.4.4 Role value\u003c/h2\u003e \u003cp\u003eSome participants found their role value, becoming the \u0026ldquo;glue\u0026rdquo; between multidisciplinary teams, the \u0026ldquo;warners\u0026rdquo; of patient risk, and the \u0026ldquo;instructor for clinical nurses\u0026rdquo;...\u003c/p\u003e \u003cp\u003e\u0026ldquo;I communicate with respiratory therapists and dieticians, discuss the outcomes of these communications with doctors, and formulate relevant plans. The doctors often take my advice. Now I act as the \u0026lsquo;glue\u0026rsquo; between them.\u0026rdquo; (N02)\u003c/p\u003e \u003cp\u003e\u0026ldquo;After rescuing a patient, I would reflect on why the patient\u0026rsquo;s condition had changed and why such a treatment plan was adopted and consult relevant literature. Then, I communicate with the doctor to sort out the procedure for rescuing such patients, provide guidance to other nurses, and supervise them in following the procedure.\u0026rdquo; (N02)\u003c/p\u003e \u003cp\u003eMeanwhile, although other participants had not yet achieved significant work outcomes, they still sensed their value through feedback from others.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I feel so proud when the doctor asks me something. As I received positive feedback.\u0026rdquo; (N02)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study represents the first attempt to explore transition experiences for APNs in mainland China, with a specific focus on novices who had been in practice for less than one month. The core finding reveals that these APNs navigated uncharted waters of their new roles. Constrained by the complexities of an unfamiliar environment, they undertook efforts to reconstruct professional identities, managed multiple responsibilities, and actively steered their own courses through this transitional phase.This study enhances our understanding of the transition of novice APNs and provides valuable insights for optimizing educational models and developing transition programs.\u003c/p\u003e \u003cp\u003eFrom a macro perspective, the practical environment refers to China\u0026rsquo;s political, cultural and social background. First, the lack of policy support is the greatest issue at present. Owing to the short history of developing APNs in mainland China, relevant health policies have not yet been introduced to define their rights and obligations, resulting in a lack of protection for the title. Concurrently, limited public awareness channels for APNs and the absence of official and authoritative information have led to low recognition. This finding has been confirmed in several studies in China[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt can be seen that at the policy level, a legal and regulatory framework that supports the development of advanced practice nursing is necessary. However, such systemic transformation can not be achieved overnight[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. It requires a stepwise implementation of pilot programs to demonstrate the significance and value of APNs within China's healthcare system. Due to the pioneering nature of APNs in China, there is limited practical research and scarce experience. As the first exploratory qualitative study in this field in China, while focusing on APNs' individual experiences, this research has revealed their environmental challenges and provided preliminary evidence of their clinical contributions. These findings lay the groundwork for developing a standardized national system for APN training, certification, and regulation in China.\u003c/p\u003e \u003cp\u003eFrom a micro perspective, the practical environment refers to institutions or departments where APNs work. We found that organizational characteristics, such as high staff turnover, a discordant atmosphere, and the inequitable treatment of APNs by the organization, such as mismatched incentives and unbalanced learning opportunities, significantly hindered the role transition of APNs. These contextual constraints contribute to more negative experiences.This phenomenon may be particularly pronounced in mainland China, where APNs are regulated at the institutional level, thereby amplifying the impact of work environment[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Our findings suggest that healthcare institutions, as the primary governing bodies of APN practice, should provide adequate support to maximize their professional potential.\u003c/p\u003e \u003cp\u003eThe transition in professional identity resulted in a sense of gap, which was not favourable in the early stage. Shifting from \u0026ldquo;expert\u0026rdquo; to \u0026ldquo;novice,\u0026rdquo; from \u0026ldquo;familiar\u0026rdquo; to \u0026ldquo;unknown,\u0026rdquo; APNs felt that they had returned to the starting point of their career[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], facing even more severe challenges than novice registered nurses with no prior knowledge, due to the unclear boundaries and responsibilities of their professional roles. These findings are consistent with those of previous studies[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e\u0026ldquo;Bystander\u0026rdquo;, \u0026ldquo;awkward\u0026rdquo;, \u0026ldquo;marginalized\u0026rdquo;, and \u0026ldquo;odd-job\u0026rdquo; were their descriptions of themselves, as their role had not yet been differentiated from other clinical roles. They found themselves caught between multiple responsibilities, leading to role overlap and potential role conflict. This ambiguous professional positionality exacerbated tensions within the workplace, such as scepticism from physicians and isolation from their nursing colleagues[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Compared with previous studies[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], the process of professional identity reconstruction in this study seems to be even more demanding. This may be due to our participants' limited tenure (less than one month), which enabled them to provide more profound insights into the challenges encountered during the initial transition phase. Participants in previous studies had generally completed their role transition, and their reflections tended to focus on the overall role changes[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur finding is consistent with other studies showing that APNs bear multiple burdens[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. However, the sources of these burdens differ from those identified in previous studies[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. APNs find it challenging to dedicate time during work hours for deep thinking and planning because they do not want to be misinterpreted as \u0026ldquo;idle\u0026rdquo; by other nurses and instead have to \u0026ldquo;disguise\u0026rdquo; themselves with multifarious workloads. This is also related to tense work relationships. Faced with doubts from colleagues, they lack the confidence to take on challenging tasks and tend to choose more basic and error-free tasks. This kind of \u0026ldquo;disguise\u0026rdquo; seems to be a unique manifestation among APNs in China, which may conceal their talents.\u003c/p\u003e \u003cp\u003eAs repeatedly mentioned in previous studies, negative emotions, including \u0026ldquo;anxious\u0026rdquo;, \u0026ldquo;frustrated\u0026rdquo;, \u0026ldquo;depressed\u0026rdquo;, and \u0026ldquo;annoyed\u0026rdquo;, occur frequently in APNs[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Insomnia and emotional eating are unique findings in this study, further highlighting the challenges and frustrations faced by APNs, particularly those with short employment durations. These findings suggest that support strategies are urgently needed.\u003c/p\u003e \u003cp\u003eProactive learning is currently the simplest and most effective coping strategy available to APNs, particularly in acquiring interdisciplinary knowledge and skills. This may be related to the current core professional positioning of Chinese APNs - solving complex multidisciplinary clinical problems. In countries such as the United States, The United Kingdom, and Singapore, the educational system for nurse prescribing is well-developed[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], with prescriptive authority established as a hallmark function of APNs[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. However, in mainland China, there is a cautious attitude towards nurse prescribing[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], and most APNs are not yet able to regard prescription decision-making as a career breakthrough[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Instead, they tend to focus on complex case management and multidisciplinary collaboration, thus forming a unique professional advantage. Therefore, the education of APNs should not be limited to cognitive development and theoretical methodologies but should also incorporate clinical interdisciplinary modules[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. For practicing APNs, it is essential to provide multidisciplinary communication platforms and support resources, such as interdisciplinary case discussions, peer support systems, and mentorship programs.\u003c/p\u003e \u003cp\u003eA master\u0026rsquo;s degree is recommended for entry level by International Council of Nurses (ICN)[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. And this criterion has been widely adopted in countries with well-established advanced practice nursing systems, such as the United States, United Kingdom, and Canada[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. The guideline published by ICN also indicates that the characteristics of APNs are shaped by the context in which they are credentialed to practice. For example, a review of APNs in Low- and lower middle-income countries revealed that the type of education ranged from continuing education and non-accredited post-registration diploma to masters[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Therefore, viable approaches for developing and implementing new APN role must be grounded in each country's specific healthcare system and nursing workforce[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Currently in China, only 0.2% of nurses hold graduate degrees[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], which presents significant challenges in directly applying the international master's degree standard. Therefore, selecting experienced bachelor's-degree nurses as potential APN candidates is a feasible strategy during the initial phase of role implementation[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough not all APNs currently hold master's degrees, this study reveals a strong aspiration for graduate education among them. This phenomenon can be attributed to multiple factors: higher educational qualification can enhances professional confidence and authority, fosters recognition within interdisciplinary teams, and increases probability of professional title advancement - collectively leading to better alignment with APN role expectations. This creates a virtuous cycle of \"education- APN role\": the APN role motivates nurses to pursue higher education, while the attainment of higher education further enhances role congruence. These findings substantiate the positive impact of APN role implementation on the professional development of nursing.\u003c/p\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Strengths and limitations\u003c/h2\u003e \u003cp\u003eThis is the first study to explore the transition experience of novice APNs within mainland China, offering some perspectives that differ from those of previous research conducted primarily in Western countries. In addition, including participants of different genders, ages, educational backgrounds, and departments contributes to the richness of the research data. However, there are several limitations in this study. An interview is a form of self-report, which may involve recall bias[\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Therefore, we selected APNs who had been employed for less than a month to minimize recall bias and directly revealed the conflicts and issues encountered during the early transition period. Moreover, this study was conducted in a city, so the generalizability of our findings may be limited. However, this is due to the small number of APNs in China, and it is also designed to achieve face-to-face and in-depth interviews to obtain the information conveyed by facial expressions and body language.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study makes novice APNs' roles and experiences more transparent. Being constrained by the practical environment, reconstructing professional identity, and bearing multiple burdens were identified as three main themes, which illustrated a grim picture of the APNs' experiences. However, despite the tumultuous initial phase of transitioning into a new role, they steered their own course, with some even realizing their professional value. Additionally, we observed unique characteristics among APNs in China, including \"disguise\" in their work and a strong desire for a graduate degree. Future research should further explore APNs' stage experiences and provide a theoretical basis for optimizing educational models and developing targeted support programs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of West China Hospital of Sichuan University (20231992). The participants were informed that they could voluntarily decide whether to participate in the study and withdraw at any time without penalty. Informed consent was obtained from all participants. Participant confidentiality was ensured by using special codes ranging from N1 to N23. In addition, only the researchers had access to the data.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests。\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNone.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eTW and JY conceptualized this study. TW conducted the interviews. TW and HQ analyzed the data. LSS, WC, WL and JY provided regular feedback during data analysis. TW wrote the first draft and substantial contributions and revisions were made by HQ, LSS, WC, WL and JY. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe express our gratitude to the advanced practice nurses who took part in this study and shared their experiences.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe dataset and analysis supporting the conclusions of this article is available under request to the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eInternational Council of Nurses,. 2020. 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Recall bias and reduction measures: an example in primary health care service utilization. 36 (5), 672\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/fampra/cmz042\u003c/span\u003e\u003cspan address=\"10.1093/fampra/cmz042\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Advanced practice nurses, Transition, Experience, China, Qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-8879966/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8879966/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTransitioning to the role of advanced practice nurses is dynamic and challenging. Deeply exploring the transition experience and developing corresponding intervention strategies can make the transition smoother. China's development of advanced practice nursing remains at a nascent stage, exhibiting localized characteristics. However, limited knowledge exists regarding experiences, feelings, and challenges of advanced practice nurses in the region. This study aims to explore the transition experiences of novice advanced practice nurses in China.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA descriptive qualitative design was used. Twenty-three advanced practice nurses was recruited using purposive sampling technique. Semi-structured and face-to-face interviews were conducted to collect the data, and the thematic analysis was used to analyse the data.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e\u0026ldquo;Navigating the\u0026ensp;uncharted waters\u0026rdquo; was the overarching theme, which linked four themes: (1) being constrained by the practical environment; (2) reconstructing professional identity; (3) bearing multiple burdens; and (4) steering my own course. Furthermore, distinctive characteristics were identified among Chinese advanced practice nurses, specifically the phenomenon of \"disguise\" in their work practice and a strong aspiration for a graduate degree.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study reveals that the role transition for advanced practice nurses is a complex and demanding process, profoundly shaped by the practical environment. The findings further highlight the importance of adaptive copingbehaviours, particularly personal resilience and proactive learning. Healthcare institutions, nursing organizations, and national policymakers should offer strong support by enhancing educational programs and developing transition plans, thereby creating a positive environment for advanced practice nurses.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003eOur study does not report healthcare interventions on human participants. Clinical trial number: not applicable.\u003c/p\u003e","manuscriptTitle":"‘Navigating the uncharted waters’- Transition experiences of novice advanced practice nurses in China: A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-27 13:51:45","doi":"10.21203/rs.3.rs-8879966/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-12T07:33:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-12T00:35:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-06T17:52:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"330689127235609842590804156062350583411","date":"2026-03-06T13:09:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"252158603932064238414019636766659411385","date":"2026-03-06T01:01:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"42340208443109581035286180044692967432","date":"2026-02-27T12:18:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-27T09:24:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"183626575826545625539717743840986375319","date":"2026-02-25T08:00:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-24T20:09:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-23T10:31:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-20T12:23:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-20T12:23:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2026-02-14T12:35:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"59aeab47-daf5-43e9-b22b-6640766be3b0","owner":[],"postedDate":"February 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T16:10:55+00:00","versionOfRecord":{"articleIdentity":"rs-8879966","link":"https://doi.org/10.1186/s12912-026-04626-8","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2026-04-06 15:59:07","publishedOnDateReadable":"April 6th, 2026"},"versionCreatedAt":"2026-02-27 13:51:45","video":"","vorDoi":"10.1186/s12912-026-04626-8","vorDoiUrl":"https://doi.org/10.1186/s12912-026-04626-8","workflowStages":[]},"version":"v1","identity":"rs-8879966","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8879966","identity":"rs-8879966","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}