Emotional Support for New Graduated Nurses in Clinical Setting: a Qualitative Study.

INTRODUCTION: Newly graduated nurses experience many stressful situations during transition to practice. The provision of emotional support from more experienced nurses can ameliorate such work-related tension. Studies have not clearly specified the means through which such support could be most effectively provided; therefore the present study was conducted to explore the experiences of qualified nurses around the provision of emotional support to newly graduated nurses.
METHODS: This qualitative study was conducted through semi-structured interviews with 18 qualified nurses. A purposive sampling approach was used for selection of participants. Interviews were transcribed verbatim and analyzed by the conventional content analysis method. The study took place from 2014-2015 in six teaching hospitals in the northwest of Iran.
RESULTS: Emotional supports emerged in four following main-categories: Assurance, creating a sense of relaxation and security, lifting spirits, and emotional belonging and involvement.
CONCLUSION: These results can help to establish an effective source of emotional support for newly graduated nurses. This can play an important role in reducing their stress and anxiety, in increasing their self-confidence and in forming a constructive relationship between them and qualified nurses.

Introduction

Newly graduated nurses have the basic academic and practical skills required for entering to work as qualified practitioners; however, because of the extensive curricula at universities, they have not been able to fully integrate their theoretical knowledge with clinical practice. Therefore, they require more experiences and needs support from other colleagues during this transition period.[1]

Consequently they are faced with numerous challenges and a great amount of stress as they commence their career.[2-5]

Newly graduated nurses often have little trust in their own capabilities and experience, a lack of confidence manifesting in behaviors such as doubtfulness about their level of performance, ethical distress and fear, and inability to appropriately communicate to other nurses, physicians, and patients,[4,6,7] Another concern for them is around entering the work group and negotiating acceptance within it. During the first few months on the job, they frequently feel unqualified, inadequate, and helpless.[5,8,9]

Moreover, newly graduated nurses may experience an extensive range of emotions, such as anxiety, fear, depression, emotional exhaustion, helplessness, feeling of immense time pressures, and despair. With these worries and a sense of a lack of control over their environment comes a substantial need for emotional support.[4,5,10,11] Without an appropriate source of support, these problems may compel them to leave the profession.[12] Emotional support during this period is mainly sought from individuals whom the new graduate sees as accepting, as well as effective clinicians.[13]

An important factor in reducing stress and preventing newly graduated nurses from leaving their job during the first few months after qualification is the availability of support programs, offered via their employer or from colleagues, in particular support from nursing personnel who are regularly presence within the clinical setting. These programs have a major effect on newly graduated nurse’s work, promote success in acquiring the basic skills of their profession and support them in coping with their new roles.[14,15]

Researchers have emphasized how vital it is to emotionally support newly graduated nurses, as it reduces their occupational stress, increases their motivation, self-confidence and satisfaction, as well as their professional competence.[16] It also improves their organizational commitment,[16,17]to the extent that they are more likely to remain in their job and keep working even under pressured circumstances.[18,19]

“Support” has been given different meanings in English dictionaries, including “to inspire, to help, to approve and to defend”, and involves positive interactions for the most part.[20,21] Support is a mutually, interpersonal and context-dependent process that makes people feel respected, valued and loved by others.[20]

Almost et al., reported that collaboration between qualified and newly graduated nurses reduced the pressure exerted on nurses and lead to creating an atmosphere of respect, support, trust and open communication between them.[22] Such positive interactions between qualified and newly graduated nurses provides the novice with respect, acceptance, involvement in making decisions that finally improve their clinical skills, self-esteem, and job satisfaction.[23]

Abedi et al., also stressed the need for supporting newly graduated nurses; however, they did not discuss the means through which this support can be provided.[23] In a study conducted by Johnstone et al., newly graduated nurses described some behaviors they considered supportive to themselves, including the accessibility of other personnel, receiving encouragement from others, receiving responses to questions and being given a sense of worth, which play a substantial role in increasing their clinical competence and self-confidence.[15]

There is a dearth of literature on transition process from school to the clinical setting, the importance of support, the lack of adequate sources of support mainly from the perspective of newly graduated nurses themselves, and also the problems faced by this group;[4,24] the majority of these articles highlighting the negative aspects of the phenomena and overlooking the positive ones.[4,7,9] Moreover, the majority of studies investigated the effect of preceptor ship and mentorship programs on the performance of newly graduated nurses. However, few studies had addressed means of providing support to novice practitioners from the perspective of the qualified nursing personnel.[15,24-27], Furthermore, studies have not clearly specified the means of providing emotional support to newly graduated nurses,[14,15,24,25] so for a deep understanding of this topic a qualitative methodology was used. Qualitative studies use various methods to assess events, norms and values and to collect relevant data from the perspective of process owners, thus allow for an in-depth, comprehensive examination and understanding of phenomena.[28]

Therefore, the present study was conducted to understand the experiences of experienced nurses about the means of providing emotional support to newly graduated nurses. There is a pressing need to conduct such studies in order to change the policies, practical plans, and attitudes of nursing personnel toward providing emotional support to this group.

Materials and methods

This qualitative study was conducted through a conventional content analysis approach.[29] A purposive sampling method was used for selection of participants and it continued until data saturation was reached. Participants included 18 qualified nurses (15 female, 3 male), all of them had a bachelor’s degree, job experience ranged between 1-27 years with mean (SD) 12.89 (7.98), and ages ranged from 23-50 years with mean (SD), 35.56 (7.9) (Table1).

Table 1

Demographic characteristics of the study participants

Participant no.	Age (year)	Gender	Occupation	Work experience ( year)
P1	50	Female	Head nurse	27
P2	44	Male	Clinical nurse	22
P3	27	Female	Clinical nurse	4
P4	27	Female	Clinical nurse	5
P5	35	Female	Clinical nurse	11
P6	28	Female	Clinical nurse	5
P7	40	Female	Clinical nurse	18
P8	40	Female	Clinical nurse	18
P9	24	Female	Novice nurse	1
P10	46	Male	Clinical nurse	26
P11	30	Female	Clinical nurse	8
P12	42	Female	Clinical nurse	17
P13	31	Female	Clinical nurse	8
P14	40	Female	Head nurse	16
P15	38	Female	Clinical nurse	15
P16	35	Male	Clinical nurse	11
P17	40	Female	Clinical nurse	18
P18	23	Female	Novice nurse	2

Inclusion criteria included as followings: agreement to participate in the study, having at least one year work experience as a full-time qualified nurse, and having a supportive relationship with at least two newly graduated nurses in the previous year. Unwillingness to continue partnership meant exclusion from study‏.

The study incorporated clinical settings such as emergency departments, intensive care units and surgery wards in six governmental, general teaching hospitals in the cities of Hamadan and Tabriz, in the northwest of Iran. This study lasted 15 months within the period of 2014-2015. Data were first collected through unstructured in-depth interviews using general questions about the experiences of qualified nurses working with newly graduated nurses, then continued with semi-structured questions such as “what needs do newly graduated staff have?” and “how do you support their emotional needs?”. Field notes and observations were also a part of the data collection method. Interviews lasted between 30 - 90 minutes.

Data was analyzed using conventional content analysis.[29] This method is composed of six stages: (a) transcribing data, reading and re-reading documents and perceiving initial ideas, (b) creating original codes: coding verbatim line by line, (c) searching for themes: contracting the codes into potential themes, (d) reviewing of themes: relating themes with each other, with extracted codes and the entire data set, (e) defining and naming themes: ongoing analysis, distillation of themes, creating apparent definitions and names for each theme, and (f) producing the report: final analysis, moving between transcripts and themes, selection of vivid stories for each theme, concluding the report.‏ MAXQDA software 10.0 R250412 was used to facilitate classification and organization of data during the process of analysis.[30]

Credibility of data was improved through long term‏ engagement with the subject. Moreover, three participants and two newly graduated nurses confirmed the compatibility of results with their experiences. To increase dependability at the beginning of study a partial review of available literature was conducted to avoid researchers' bias in data gathering and analysis processes. Confirmability was achieved by cautiously recording and reporting the steps of study and decisions made, to facilitate repetition of the process for other researchers. Emphasis was placed on achieving diversity in participants’ clinical backgrounds to aid transferability of findings.

Ethics approval was sought from the Regional Medical Research Ethics Committee, and was granted for a study involving human subjects. In addition, permission to access the study site and participants was granted from hospital managers. Prior to beginning the study, potential participants were informed of the study goals, of the voluntary nature of their possible engagement, and of steps taken to ensure confidentiality of data. Written consent was obtained from all participants for their contribution, which included planned recording of interviews, and anonymous publication of findings.

Results

Four major main-categories emerged from the data analysis: “assurance”, “creating a sense of relaxation and security”, “lifting spirits” and “emotional belonging and involvement”. The overlapping of the four main-categories facilitated the participants’ perception of emotional support for newly graduate nurses within the practice setting (Table2), as follows:

Table 2

Categories and sub-categories related to emotional support

Them	Categories
Emotional Support
	Assurance
	Access to supporters
	Confidentiality
	Approval
	Creating a sense of relaxation and security
	Non-aggressive verbal and non-verbal behaviors
	Patience
	Lifting Spirits
	Encourage
	Valuing the dignity of individuals
	Cultivating the seeds of hope
	Fostering spiritual motivation
	Emotional belonging and involvement
	Acceptance
	Understanding

1. Assurance

Assurance involved the access to supports, confidentiality, and approval, as follows:

1.1. Access to supports

Participants assured newly graduated nurses that they were constantly present by their side and that they could easily count on the support and help of the nurses and doctors if they needed a help. During their initial practice experience, and to assure new graduated nurses of their helpfulness, nursing personnel accompanied newly graduated nurses throughout their clinical procedures without making them nervous or letting the patients realize that they were novices. They also assured newly graduated nurses that they would subtly check on their work, just to help them and to make them aware that they looked after them, but from a distance

I tell new nurses to ask any questions they might have or to tell me of anything I can do for them when they work with me in my shift and to otherwise phone me if I wasn't on shift and there was no one else around to help"(P5). “I’m here for you if you need me” or “Don’t worry (P3).

1.2. Confidentiality

One of the concepts extracted from the data was confidentiality, which plays an important role in creating mutual trust. In the case of an inadvertent negligible mistake by the new graduated nurses, they were privately and subtly instructed by the doctors or experienced nursing personnel so as to prevent notions of mistrust in the patients. Qualified nurses emphasized for newly graduated nurses that if they did not know how to perform a certain task, or if they had any particular problems, needs, or any concerns that they did not want others to find out about, they could talk to them in confidentiality.

"Sometimes new nurses are afraid of talking about their problems to us, since they fear that we might inform the supervisor or the head nurse. I try to convince them that they will not be hurt by trusting me"(P8).

1.3.Approval

According to participant’s statement, newly graduated nurses have a great knowledge but lack self-confidence and border on obsession about whether or not they have performed their tasks properly.

To increase their self-confidence, qualified nurses occasionally approved their performance non-verbally by simply nodding their heads or giving an approving look in the presence of patients, and sometimes this was done verbally by complementing them on their knowledge and skills in the presence of their colleagues. In the opinion of qualified nurses, giving approval is vital, especially during the first 3 or 4 months of starting the job. In the initial days of a new career the novice would frequently experience fear, anxiety, stress, and even despair. It was reinforced with them that those feelings are normal.

"I help new nurses get to know themselves and generate in them the feeling that they can handle patient care. For instance, if they do things right, I nod my head if we are by the patient's bedside to show my approval"(P12).

2. Creating a sense of relaxation and security

This included Non-aggressive verbal and non-verbal behaviors, and patience, as follows:

2.1. Non-aggressive verbal and non-verbal behaviors

In communicating with the newly graduated nurses, qualified nurses maintained their relaxed body pose and avoided yelling and harsh, destructive criticism and tried not to display any behavior that could be misconstrued as aggressive, and through that avoided imposing additional stress on the novices. Such a strategy prevents newly graduated nurses from forming mistrust and seeking isolation from the other personnel.

"It is so important for me to have a relaxed body pose when talking to new graduated nurses and to avoid transferring aggression and partiality to them. I have seen that behaviors associated with aggression can cause stress and anxiety in new graduated nurses and make them lose their trust in me as the nurse who is meant to support her"(P16).

2.2. Patience

Participants asserted that it was quite natural for newly graduated nurses not to be as adept and prepared to work as effectively in the clinical setting as qualified nurses are, and to need the proper support and the right amount of time and experience to achieve this. They argued that they should be patient with the novice nurses, to give them the opportunity to familiarize themselves with the new setting and its expectations of them, and to not expect from them what is not in their power.

"It is a new environment, most of them are not familiar with this setting, patients, and routine work, we will be patient for the deficiencies of their work to be solved, we give them opportunity to acquire required competencies"(P4).

3. Lifting Spirits

This category included encourage, valuing the dignity of individuals, cultivating the seeds of hope, fostering spiritual motivation, as follows:

3.1. Encourage

Encourage is an important influential factor in providing emotional support to newly graduated nurses. To achieve this objective and to nourish their inner motivation, nursing personnel assigned newly graduated nurses with easier tasks that were within their capabilities during their first few days or months and praised them in the presence of others for correctly performing the tasks. They encouraged them to learn, to perform independently, improving their skills and enabling them to ask questions. If any of the newly graduated nurses demonstrated any special skills, they used those skills to teach some points to other newly graduated nurses or to themselves so as to increase the newly graduated nurses' motivation for working and learning. Because of their mutual understanding and their similarities in position and age, newly graduated nurses are better suited for helping each other out. In their experience, qualified nurses prefer to help out those who are highly motivated and confident.

"I encourage them to learn things and to increase their knowledge of drugs and the patients in their ward. I stress that the more capable they are, the higher will be their own and their profession's value and respect"(P11).

3.2. Valuing the dignity of individuals

To achieve this objective, head nurses allocated some time to hearing their new graduated nurses' problems in the afternoon and night shifts. They sought their opinions in making decisions and implemented their useful suggestions. The personnel also happily answered their questions. Any warning or criticism was given in private. All these measures increased their confidence and brought greater mutual trust and communication

"Nurses who work in the afternoon or night shifts face with more challenges. I listen to them and help out as much as I can. If I have to warn them, I do it in private, so that the patients, colleagues and general service personnel do not hear a thing, because it is hard for them"(P7).

3.3. Cultivating the seeds of hope

Hope is a concept that encourages people to make an effort in life. Nursing personnel reminded newly graduated nurses that, in Iran, employment conditions and job benefits were much better for nursing than for many other professions. They would gradually learn the best way of dealing with the job, and that handling the greater amount of stress and the many problems faced in intensive care units would make them more experienced and would prepare them for permanent employment in the future.

"I tell them that, in this country, nursing is better than many other jobs. There's enough work for nurses, and the salary is kind of good. Many people wish they could study nursing, but they can't. And I tell them that we were just like you at first, but then learnt things"(P9).

3.4. Fostering spiritual motivation

Another concept extracted in the present study was fostering spiritual motivation in newly graduated nurses. To increase their patience during hardships, they were told how serving God's creatures was among the best kinds of worship. God should be considered in all matters as He watches over all our acts and the Divine grace is the best reward for our work.

"God should be considered first and foremost in all matters and the only things one should think about are that God is always watching and also the Divine grace, and only then come in salary and benefits"(P18).

4. Emotional belonging and involvement

This included acceptance, understanding, as follows:

4.1. Acceptance

During the first days, newly graduated nurses are like guests, therefore feeling like strangers. They are faced with resistance to change from the more experienced personnel. Many such qualified nurses suggested that they were indeed welcoming, wishing well, and respectful of the newcomers. They invited them to their work station and talked to them so as to diminish their sense of being outsiders; however, acceptance also depends on the characteristics and communication skills of the newly graduated nurses themselves. Compared to the male personnel, the female personnel tend to be quicker at accepting newly graduated nurses into their group and giving them emotional support

“I welcome to them, and I invite them to the station, and talk to them"(P3).

4.2. Understanding

Nursing personnel actively listened to the problems the new graduated nurses might have encountered as newcomers, comforted them and tried their best not to leave them without help. They were helped to solve their problems and deal with their concerns. Asking questions around their experiences and feelings generated a sense of empathy.

"Sometimes new graduated nurses don't sit with us, and then I go and sit next to them and invite them to come over and sit with us. And then we try not to make them feel left out by whispering in each other's ears and using gestures to talk"(P2).

Discussion

In this study, we found that emotional supports for newly graduated nurses included techniques that‏ were used by qualified nurses to minimize unpleasant emotion surrounding their clinical induction. They reported utilizing a diversity of techniques to achieve this, including attending to body language, reassure them that feelings such as fear, anxiety, stress, and‏ despair are normal during initial months entering practice, asking questions about the needs and feelings of novice nurses and listening actively to their problems, some of these techniques have been recommended sporadically within some previous studies.[24,31-36]

According to the prior studies, newly graduated nurses are usually uncertain about their performance of tasks.[4,6]

Participants in the present study appeared to have understood the likelihood of such problems, since their reported reassurance of newly graduated nurses was among the main themes extracted from the data, and was demonstrated through such behaviors as assuring newly graduated nurses of their constant presence at the bedside for helping out whenever required, their monitoring of the novices patient care duties with subtlety and benevolence, their maintaining of the confidentiality of the newly graduated nurses' personal information, and their overlooking of the their small mistakes within the workplace.

Qualified nurse’s approval of their knowledge and skills, through these behaviors, assured novice nurses that they were on the right track and projected a readiness to support with any problems they might face. According to a study conducted by Coffman, merely saying don't worry, someone will be there if you need help, makes newly graduated nurses feel assured and trusting.[37]

Another problem which newly graduated nurses faces with was the lack of confidence,[4,6] but supportive, qualified nurses improved this trait through such behaviors as increasing their motivation, inspiring hope and creating a sense of worthiness, usefulness and acceptance.

Consistent with this study, Duchscher et al., demonstrated that the acceptance of newly graduated nurses increased their self-confidence and led to a greater effort on their part for overcoming their problems.[4]

Newly graduated nurses do not have continued access to their student peers, their friends or teachers and enter a new environment that they do not yet recognize; thereby, they feel alone and isolated and need to be accepted by more experienced nursing personnel.[1] To solve these problems, qualified nurses treated them with empathy, acceptance, and invited them into their group through welcoming, respectful, and courteous behaviors.

Some studies have reported stress and anxiety in newly graduated nurses in entering clinical setting‏.[2,3,5] This stress was successfully reduced through non-aggressive verbal and non-verbal behaviors, showing patience around their shortcomings and via giving ample opportunity to get familiarized with the new setting and its expectations. Fostering spiritual motivation was another theme extracted in the present study, which was shown to increase newly graduated nurses' patience in times of hardship and to reduce their stress; however, no other studies have discussed this factor that motivates working and supports the novice nurses efforts.

Before trying to provide support for newly graduated nurses, qualified nurses must make sure that they are in an emotionally healthy place yourself and calm. Connett[21]argues that maintaining a relaxed body poses reduces anxiety, stress and uncertainty.

The concept of emotional support extracted in the present study from the experiences of qualified nurses, as mentors of newly graduated nurses, is consistent with the concepts extracted in other studies conducted on such novice practitioners' from own perspective of supportive behaviors. Such behaviors include the provision of encouragement around their performance of patient care, the creation of opportunities for autonomous performance, the availability for help where required, an environment encouraging inquisitiveness, colleagues responding to questions, providing impartial guidance and creating a sense of worth; these studies increase the validity of the data obtained by the present study‏.[24,32,33,38]

Participants suggested that emotional support included providing encouragement, expressions of caring, reassurance, attentive listening, and commonly avoiding criticism or exhortatory advice-giving, which was consistent with the finding of Dennis study‏.[39]‏

Compared to their male counterparts, female nursing personnel are quicker to become friendly with newly graduated nurses and provide more emotional support to them. Nevertheless, they minimize their support with the smallest of misunderstandings between them and new graduated nurses. Male personnel tend to take more time to become friendly, but their support lasts longer.[12]

The main limitation of this study includes concepts presented in the study that might be misconstrued as suggestive of a utopia and representing the best possible performance. However, due to the word length limitations on the study and in order to avoid boring the reader, many other issues related to the concept of support were left out from the study. The present study mainly addressed the positive points in order to present nursing personnel with clear examples of how to provide emotional support to newly graduated nurses.

Conclusion

These finding can help establish an effective source of emotional support for newly graduated nurses that can play an important role in reducing their stress and anxiety, increasing their self-confidence, and in forming a constructive relationship between experienced staff and newly graduated nurses. To provide emotional support for newly graduated nurses, it does not require special expertise; it suffices to show a good will, openness, kindness of heart and altruism.

Further studies of this subject are recommended to better understand the unique perspective of newly graduated nurses around the emotional support they have received from their colleagues, and also to explore the effect of emotional support on their self-esteem, the formation of trust and a constructive relationship between them and their more experienced peers.

Acknowledgments

The authors would like to express their gratitude to the Student Research Committee and all the participants who kindly helped conduct this study.

Ethical issues

None to be declared.

Conflict of interest

The authors declare no conflict of interest in this study‏.