Perception of Senior Nurses regarding the Transition of Newly Graduated Nurses at Colonial War Memorial Hospital, Fiji ()
1. Introduction
There is an increased turnover of medical personals as health care evolves, increasing technological demands and complexity of patients with an increase in the global shortages of nurses as a severe health challenge [1]-[4]. Transition into clinical practice for newly graduated nurses (NGNs) has been reported to be a challenging event whereby registered nurses feel incapable of carrying out duties independently in a clinical area soon after graduation [5]. Major challenges NGNs face include stress, emotional exhaustion, practicing in acute care settings, coping mechanisms and the delivering safe nursing practices are causes for concern [6]. One of the biggest and unacknowledged challenges faced by NGNs is “that they are caught in tension between the industry and education as they are prepared by the education system” [2]. Transition as a process of change is subjective to the role and the changes that occur in structures, functions and dynamics [7]. The nursing care in the hospital setting is ever-changing and the need for competent and skillful registered nurses is required, who can provide quality and safe patient care [8]. Additionally, the rise of chronic illness requires community-based nursing care [9].
Nursing is a competency-based profession where nurses must apply their know-ledge, skills, and affection to provide quality patient care [10]. New graduates must also be well equipped to provide the expected quality care with continuous support through induction programmes and mentoring by senior nurses for the development of the skills [11] [12].
Fiji has recently experienced skilled migrations of registered nurses including NGNs, in search of better working and living conditions through international migration thus increasing the need to create a health workforce [13] [14]. Proper training and supervision can only be possible if there are guidelines in place for senior nurses to guide and teach the new nurses. The quality of transition will enable new nurses to gain confidence and remain in the service after their internship [15]. Goundan, says new nurses experience mixed feelings as they commenced their journey of internship. The author carried out a study in Labasa, Fiji Island, with twenty-two (22) participants who mentioned internship being a “significant phase” of their lives (p. 4). Intern nurses found new discoveries while working during the transition period feeling an increase in the responsibilities, they are given compared to being a student nurse [12] [16]. A study conducted in CWM (Fiji) stated that NGNs mentioned feeling overwhelmed and had an increase in the responsibilities compared to that of during student days.
The study by [15] further states that a smooth transition is required for intern nurses with a supportive environment and preceptorship programs. Therefore, the need to investigate the challenges faced by senior registered nurses in supervising NGNs, and what resources they need to better supervise these nurses effectively and efficiently.
New nurses face several challenges as they transition from nursing students to working nurses. A mentorship program will help ease the uncertainty by giving extra teaching and support transition into the workforce through preceptorship and clinical supervision [17] which the new graduate requires. [1], mentioned that new graduates experience difficulties while adapting to their new jobs and transitioning to practice in a stressful and complex environment due to lack of clinical knowledge and self-confidence. Lack of support from colleagues, senior nurses and preceptors can result in the stress experienced by NGNs. Registered nurses in a study reported that NGNs are not prepared for performing advanced skills [3].
Internship programs are used worldwide to assist new graduates to function fully and adequately in the clinical environment. Support by senior nurses and a good mentorship program guides NGNs.
Nurse mentoring programs increase new nurses’ intent to stay and improve retention rates [14] [15] who will be satisfied with clinical supervision [1] supportive environment is provided to the new nurses [10], will enable a smooth transition which is critical for the new nurses [15]. This study was prompted to explore the experiences of senior nurses while they mentor NGNs, to better understand their situation and what they would like to have placed in the preceptorship manual.
2. Literature Review
Introduction
The health-care environment is ever-changing and with these changes comes the demand for professionals who are well equipped with knowledge and clinical expertise. The need is more critical than ever before, thus having to understand how the changes in health care impacts NGNs who are transitioning to practice in this ever-changing environment [11]. Nursing shortages due to migration to other countries is prevalent in Fiji, leaving young graduates to take over the roles of the senior nurses who migrated [8]. Transitioning to a new environment can be a challenging event leading NGNs to feel frustrated and lack confidence to carry on the job of a registered nurse. Adequate clinical support structures provided during this crucial period can assist NGNs to perform better and with confidence and function completely in the wards [18].
Nursing students, after graduation, embark into a journey of transition to a professional graduate registered nurse [8]. New graduate nurses’ transition is a complex and challenging experience as they adjust to the new professional role [9] new graduate nurses experience challenges and difficulties while they adapt to the new jobs during transition to practice in a stressful and complex work environment [1]. To become a successful member of the health care force, NGNs need to gain confidence, the ability to perform high critical care nursing, deal with high patient numbers, the ability to work independently in the ward, and manage relationships with providers and families and the interprofessional team [1] [8] [9] [12].
For a successful transition, NGNs need a preceptor program that will assist senior nurses to continuously monitor, guide, teach and make the NGN familiar with the demanding work environment in any setting within the health care environment. [19] mentioned in their study that a supportive environment is needed to allow novice nurses to gain experience and a need for preceptor support, guidance, teaching, and continued practice of skills. Appropriate support will help alleviate the uncertainty and build their confidence.
A preceptorship program must be formulated to assist senior nurses while they mentor, assist, teach and guide NGN transitioning to professional roles. [18] mentioned that NGNs reported lack of support and unavailability of experienced nursing staff to shadow graduate nurses, therefore, having a preceptor program could assist the NGNs during the transition. [13] suggest that fatigue also needs to be addressed in the preceptorship program. Senior nurses are expected to provide quality care for patients, coaching and mentoring younger nurses, but are faced with shortages in their environment. A study reported that professional nurses saw new nurse graduates as an answer to fill in for the shortages and share workload with the senior nurses [20]. There were high expectations from the registered nurses that NGNs could perform certain duties and procedures independently and reflected a change in identity [8].
When senior nurses are assigned to NGNs, they must give in their own time and effort, having a load for themselves, they work overtime, get stressed and overwhelmed with the amount of work they must carry out daily. Yet they are also assigned to mentor new nurses who need constant supervision, teaching and guiding them may not be an easy task. The conditions in which registered nurses work in CWMH are a concern with lack of resources being a huge concern.
[21] states that clinical supervision is left for the clinicians to take over, having more than six (6) students in any shift to supervise, senior nurses are given another responsibility of guiding NGNs in their wards. Yet there is no support provided to senior nurses, to be relieved of the significant amount of nursing duties to carry out such extensive responsibilities of supervising student nurses, NGNs and medical students. On the other hand, senior nurses have been working in the field for many years, some have spent their entire nursing career in the wards but had never had any supernumeraries provided for the enormous amount of work carried out daily. In addition, [8] states that NGNs find it difficult to cope with the workload, being left on their own to carry out duties which they are not familiar with while taking charge of a shift too early in their career. No support programs are available for the new nurse due to lack of resources, and manpower, which does not allow them the luxury to be under supervision even during internship [20]. Moreover, preceptors need time and training to develop the necessary skills to assist NGNs effectively.
Several transitional programs such as preceptorship are essential and have been framed in developed countries which aid the registered nurses to competently support NGNs in their transition from novice to becoming experts [22]. Preceptorship programs will increase the intention of the NGN to stay in the workforce, therefore reducing human resource shortages.
There are no preceptorship programs in Fiji although the School of Nursing through Fiji National University (FNU) used to run programs of preceptorship with our clinical counterparts, it is not activated in the last decade [19]. Assisting senior nurses to be able to guide and support NGNs is vital as NGNs will be part of the human resource and take over the nursing duties from these senior nurses. It is important that a preceptorship program is developed for the registered nurses in Fiji, which is funded, and senior nurses are trained on it’s use, they are also given super-numeration for the extra work they are assigned to do. When senior nurses are well trained to support the NGN they will provide adequate support, this will in turn lead to a satisfied workforce, energized and ready to serve the people of their country. Problems such as bullying, fatigue and burnout will also be addressed as stated by [13].
3. Study Methods
A qualitative descriptive research design was employed to explore how senior registered nurses feel about mentoring NGNs in their work environment and the type of assistance NGNs they need as they transition into the profession of graduate nurses.
This study also aimed to produce a preceptorship program for NGNs and their supervision in Fiji.
This pilot study was conducted at the CWMH, Fiji, with two senior registered nurses who are mentors of NGNs in the hospital were recruited using a purposive sampling method for the study.
3.1. Data Analysis
While data collection is still going on, the researchers probed to understand vague or inconsistent comments. Transcription of the audio tapes was done followed by analyzing the transcribed data. A report of the interviews was done in a question-by-question format and quotes were then amplified. Later, within the week analysis of the data from both the interviews was carried out by comparing the results of both the interviews, looking for themes which emerge from each question and then having an overall assessment of the themes. Meaningful segments were clustered together aligning to the thematic codes. A master list is kept, and codes are reapplied to new segments of data whenever an appropriate segment is encountered [23].
3.2. Ethical Considerations
Ethics approval was sought from the College Human Health Research and Ethics Committee (CHHREC: ID 078-23). A written approval from the Medical Superintendent (MS) and the Director of Nursing (DON) at the CWMH was also sought prior to commencing the research interview.
Confidentiality of participants was strictly observed. Their identities were coded. All information derived during the recruiting process, interview, and recording of the interview were password protected.
Participants
Two participants were interviewed during the pilot study who supervise and train NGNs in their wards. The table below explains their roles and responsibilities.
Table 1. A summary of the participants’ roles and responsibilities.
Description |
Roles and responsibilities |
Participant 1 is a Nurse Unit Manager (NUM1) |
Patient care: Works in a 22-bed flexi unit with medical and
surgical patients. Works eight hours shifts per day. Oversees registered nurses. Orientation and supervision of nursing and medical students. Stock takes of consumables, Overall day-to-day running of the unit, include writing reports, admission and discharge of patients. |
Participant 2 is a Senior Nurse Unit Manager for the children’s ward
(NUM 2) |
Patient care: Works in a 60 bed children’s ward with medical and surgical patients. Works eight hours shifts per day. Oversees registered nurses. Orientation and supervision of nursing and medical students. Stock takes of consumables. Overall day-to-day running of the unit, including supervision of two team leaders, doctor’s surgical and medical rounds,
admissions and discharge of patients, family conferences,
rostering of staff and human resource management. |
4. Results
Two themes emerged from the pilot study: i) responsibilities and ii) challenges.
Theme 1:
Responsibilities
Table 2. A summary of the responsibilities described by the NUMS.
Responsibilities reported by participants as priority over mentoring of NGNs |
Supervising NGNs |
NGNs transition is an added responsibility. |
Counsellors |
NUMs counsel NGNs for disciplinary issues or develop solutions to incorrect implementation of a clinical procedure. |
Time Constraints |
Having a direct patient care workload affects their ability to teach and train the NGNs especially when there is a critically ill patient. “I will jump in if there is not enough staff, but I take them to the room so that I can teach them”. (NUM2) “We don’t have time to supervise the new graduates whole day” (NUM1). |
Fill in for RN. |
NUMs care, they fill in when an RN is absent, when patient care is demanding. Currently there is a shortage of nurses in their wards, with only two to three RNs with direct contact with patients, it becomes difficult for the senior nurses to teach and guide the NGNs well. “I would say that Some part I am also lacking as we don’t have to supervise, we don’t have that kind of time to supervise for e.g. the senior nurses are busy they are not able to supervise the NGN most of the time we are not able to supervise the interns well the main factor is time”. |
Duty of Care |
They have a duty of care for the patients in their wards. They also attend to emergency situations in the ward. “They should be supervised, that’s part of the staff workload” |
Managerial duties |
Senior nurses are responsible to ensure that enough registered nurses are rostered within a shift, allocation of beds for new admissions and discharging patients from the wards. |
Teaching |
Teaching NGNs sometime is difficult when NUMs have to take care of patients in their wards, or they have to be part of the decision
making of the wards, attend meetings and so on. “To have someone here in the ward to have time to teach the NGN”. (NUM1) “I don’t have time; I want to have someone to take care of them in the wards”. (NUM2) |
4.1. Theme 1
4.1.1. Sub Theme 1: Supervising NGNs
NGNs transition is an added responsibility, especially when NGNs show some undesirable attitude towards learning and adapting to an unfamiliar environment. The increased workload on Senior nurses has revealed that they do not have ample time to support the NGNS in their wards. Supervising nursing students and mentoring new graduates is a crucial responsibility of senior nurses who are among those migrating, adding onto the extra load on those who remain in the service [3]. Senior nurses perceive that their workload restricts them from focusing on the NGNs learning process, follow them through the day’s work and supervise during nursing procedures as highlighted in Table 1. This leaves NGNs to work on their own, where mistakes are prone to happen. Senior nurses also expressed their concern on how NGNs show their willingness to learn by asking questions and participating in discussions during patient care. A study conducted in Saudi Arabia by [24] mentioned that NGNs were appreciative of the trainers who taught them to deal with patients and gain important knowledge and skills, answering their questions effectively.
4.1.2. Sub Theme 2: Counselors
The added responsibility of being a counselor while the Senior nurses supervise the NGNs plays an important role and adds to the workload which is noted from the responsibilities as highlighted in Table 1. Counselling is done when some NGNs report late to work or do not turn up to their allocated shift. Senior nurses also refer NGNs to their managers and the DDON in some instances.
“If they don’t listen to us then we refer them to the DDON”. NUM1
“Well, I talk to them, when I am counseling them, it is like they want to follow” NUM2.
4.1.3. Sub Theme 3: Time Constraints
NUMs reported that they do not have time to supervise the NGNs in their ward and relates to the duties they are required to complete within a day (Table 2).
“We don’t have time to supervise new graduates”. NUM1
“No time to give to interns”. NUM2
“With the current situation, we are expected to do the work and when the interns are not supervised all the time, and all the errors arise”. NUM1
4.1.4. Sub Theme 4: Fill in for RN
Considering the heavy workload of the senior nurses and the responsibilities they must undertake; a huge amount of time is spent on direct patient care in the ward which is short-staffed. They usually have bed allocations during the day shift with a considerable number of responsibilities to take care of.
“I do 8-4:30pm shift every day and I am always in the ward to look after patient as we have only 2 staff per shift in a 22-bed unit”. NUM1
“For me, yes I will jump in if there is not enough staff, but I take them to the room so that I can teach them”. NUM2
4.1.5. Sub Theme 5: Duty of Care
Senior nurses voiced feeling obliged to educate the NGNs as it is their duty, to have someone to take care of them in the ward.
“They should have proper activities during induction”. “They should be supervised, it’s part of our staff duty list”. “Especially for me I am someone who likes to teach, I collect them to teach them. One drawback is that, so I stop asking questions because there is someone listening to our discussions”. NUM2
4.2. Theme 2
4.2.1. Challenges
This pilot study reports on the attitude of learning by the NGNs, as observed by the senior nurses during the transition. As mentioned by one senior nurse that “the attitude of the NGN when they are ready to answer back and do not have the right attitude towards learning” (NUM2).
Table 3. Describes the challenges the Senior nurses face while supervising NGNs in their ward.
Challenges faced by participants while mentoring of NGNs |
NGNs attitude towards |
NGNs show undesirable attitudes towards learning. They answer back to the senior nurses. There is a generation gap while NGNs interact with senior nurses. NGNs also report late to work and do not give any explanation about their lateness. “The NGNs show attitude of not learning, it’s a bit challenging”. “We take time to teach but some don’t want to learn”. |
Respect for the senior nurse |
Some NGNs do not show respect to senior nurses. They are ready to answer back. “We have learnt how to respect our seniors but some, they talk back saying we know, we know”. (NUM1) |
Inconsistency while carrying out
procedures |
There is something missing in the curriculum that the NGNs are not able to carry out procedures as required. There are some
procedures which are not taught in school. “There is a miss, maybe in the practical part of the curriculum that is seen among these interns” (NUM2) |
NGNs do not ask for help |
NGNs do feel the obligation to ask for help if they do not
understand anything in the workplace. They would carry
out the procedure even if they are not sure of how it is done. |
Support from senior nurses |
Lack of time constraints limits support given to NGNs by the
senior nurses. Heavy workload of senior nurses plays a vital
role in supervision during procedures so that NGNs learn
their procedures well. |
A structured approach to monitor the NGNs can build confidence and autonomy and enhance competency. Mentoring programs are needed to assist senior nurses to establish effective communication and interpersonal relationships with the NGNs [13] to develop quality nurses in the field will depend on the quality of role models who aid them thus strengthening the importance of the mentor as a positive role model [25]. Professional communication skills and the ability to solve problems are enhanced through proper mentorship [26], this is also described in Table 3 where senior nurses feel the attitude of NGNs need to be professional.
The attitude of new nurses can be very challenging when they do not cooperate with the senior nurses is described in Table 3. The results of this study are also similar to [27] where senior nurses report the attitude of new graduates when they were taught about patient care. The attitude of NGNs could be improved by providing support through a preceptor-preceptee relationship that is strong as the key to a successful transition [28]. Moreover, proper training for the preceptors, who understand how to instruct the NGNs would also assist in improving the attitude of NGNs during transition (Arroyo, 2024).
“Some NGNs like to be taught but some do not want to learn, they show their attitude, for example one nurse asked an NGN; have you emptied the IDC? one NGN replied, it’s your job. That’s why some senior nurses don’t want to teach them” with that kind of attitude it’s a bit of a challenge” (NUM1)
“From us coming out of Nursing school we know how to respect our seniors but now they are ready to say, “Yes I know”. “They do not have any respect for seniors” (NUM2)
“We take time to teach but some don’t want to learn” (NUM2)
However, it was mentioned that “some NGNs are easy to teach some don’t take it seriously, they look at us it’s like 50/50 when we teach them”. (NUM2)
Moreover, it was mentioned that NGNs are reporting late to work or even not turning up to work and they do not inform the senior nurse about their absence.
4.2.2. Theme 2: Sub Theme: 3 Inconsistencies While Carrying out Procedures
Adding to the challenge is the fact that SNs feel that there is something missing along the way from Academia to clinical practice. Similarly, [23] also report novice nurse should possess soft skills such as social skills whereby, they can work with other persons in the team and having weak social skills will create conflicts among the team.
“NGNs are not taught certain procedures from school, and they do not know how to perform them after graduation”. (NUM2)
“Looks like a practical part is missing, especially the procedures, they say they are not taught”. (NUM1)
However, [21] mentioned that senior nurses expected new graduates to be honest if they did not know anything about patient care.
4.2.3. Theme 2: Sub Theme 4: NGNs Do Not Ask for Help
Senior nurses mentioned the NGNs would carry out procedures and would not ask for help when needed. Focusing on the soft skills attributes of the NGNs by the education body could prepare NGNs to communicate their issues with the senior nurses. As mentioned by [3] the simulation could be used to enhance communication skills.
4.2.4. Theme 2: Sub Theme 5
Support from senior nurses.
Lack of time constraints limits support given to NGNs by the senior nurses. Heavy workload of senior nurses plays a vital role in supervision during procedures so that NGNs learn their procedures well.
NUM1 “We don’t have time to supervise the new graduates, whole day and we don’t have time to supervise”.
NUM2 “Only a few of them have time to teach them”.
Participants had their responsibilities to take care of while they supervise the NGNs in their units. They expressed concern about some NGN’s attitude toward learning and found NGNs to be aware of certain procedures. They would either carry out the procedures differently or ignore certain steps during the procedures.
5. Recommendations
The senior nurses in this study gave insightful information about the challenges they face during supervision of the NGNs in the wards. Senior nurses require support from the management for training the NGNs during the transition. They mentioned that there is a need to allocate a mentor in the wards to supervise the NGNs in the wards. Staffing issues may hinder the manager for appointing mentors in the wards, but reducing the workload for a senior nurse who is responsible for precepting for the NGNs would aid in assisting them during transition. Including a preceptorship manual with a set of activities that will guide the senior nurses to effectively assist NGNs during the transition.
The reported statistics on nurse attrition rates show a concerning trend, highlighting the urgent need for improved mentorships and support systems that can effectively address the current challenges of new nurses and reduce the disparities between academic training and clinical practice.
6. Discussions and Conclusions
This pilot project has given insightful information about the experiences on SNs who train and supervise NGNs during transitions. SNs face difficulties, and challenges in many forms, there are no mentors especially for the NGNs in any wards at the CWM Hospital however, [3] report that new graduates were prepared well in terms of communication and for practice. Senior Nurses take up various responsibilities in their capacity as a senior nurse or as a NUM, providing support and supervising the NGNs becomes a hurdle for them. Senior nurses perceive NGNs as future nurses and want to train them well, but some NGNs have undesirable attitudes that hinder the learning and teaching process during transition. They also acknowledge that support and supervision is key to a successful transition, but NGNs also need to play their role in learning to adapt to the new clinical environment with various challenges they face themselves. This study is similar to [29] that there is a change in the way supervision is perceived by students and new graduates. Similarly, [21] highlights the new nurses need to create a proactive behavior of learning and adjusting to their new environment. Reducing the responsibilities laid upon the senior nurses who train and supervise the NGNs would solve the problem of undesirable attitude shown by NGNs, thus they will have time to teach the NGNs effectively and efficiently.
To increase the retention rates of nurses in the workforce, it is essential that Senior nurses are given ample time to support the NGNs during transition which could be provided through a preceptorship manual which will assist and guide the nurses to mentor the NGNs. [30] report that NGNs should be able to fit in their new roles adequately there is a need for support systems in place. The findings of this pilot study have paved the way for the main project, and in future, research should focus on advocating for mentors in special areas within the training hospitals. Allocating a senior nurse with reduced workload to be in-charge of the NGNs will help with proper mentoring. As the mentor will have some time which is dedicated towards the supervision and support of the NGNs in their wards.
Study Limitations
As a pilot study there were no study limitations. Both interviews went as scheduled.
Author Contribution Statement
Samsun Ayub: Conceived and designed the study proposal; Conducted the interviews; transcribed one interview. Analyzed and interpreted the data; analysis tools or data; Wrote the paper.
Laisa Tikomaimaleya: assisted in conducting the interviews.
Vani Rainima: Assisted in taking notes during the interviews and did transcriptions for one pilot interview.
Data Availability Statement
The data that has been used is confidential.
List of Acronyms
CWMH Colonial War Memorial Hospital
DON Director of Nursing
DDON Deputy Director of Nursing
NGN New Graduate Nurse
SONFNU School of Nursing Fiji National University
SN Senior Nurse
Glossary of Terms
Experiences
Workload
Preceptorship
Mentoring
Transition