Abstract
Orientation: Globally, healthcare workplace environment is regarded as complex and interactive in nature, hence a supportive collegial environment is crucial in professional socialisation of newly qualified registered nurses, particularly (regulation regarding bridging course [R.683]) cohort who were labelled to can ‘hit the floor running’ due to their previous enrolled nursing experience. Employees friendly workplace environments are associated with job satisfaction, less stress and intent to abandon the nursing profession. Hence newly qualified registered nurses need support in their initial period of employment.
Research purpose: The study explored and described the experiences of workplace environment by newly qualified registered nurses (NQRNs) (R.683) in their first 18 months of employment in selected hospitals of Limpopo province, South Africa.
Motivation for the study: Previous studies documented much about challenges experienced by newly qualified registered nurses in their first year, yet less has been revealed from the views of newly qualified registered nurses (R.683) who upgraded from enrolled nursing about their workplace environment experiences in their first 18 months of employment.
Research approach/design and method: The researcher used a qualitative approach following explorative, descriptive and contextual design. Seven focus group interviews were conducted with a sample of 51 newly qualified registered nurses (R.683), who were purposively sampled in their first 18 months of employment in different units of selected hospitals from Mopani and Vhembe districts of Limpopo province South Africa. Thematic analysis revealed one theme and five sub-themes that negatively influence their perception on workplace environment: negative attitudes and behaviours, bullying, lack of orientation, shortage of staff and workload, and insubordination.
Main findings: Contrary to what has often been assumed, that newly qualified registered nurses (R.683) are work ready because they possess previous nursing experience. Our findings indicate that regardless of previous nursing experience, NQRNs’ (R.683) re-entry into the workplace environment is overwhelming and stressful like any other newly qualified nurse, hence they perceived their workplace environment as negative.
Practical/managerial implications: Nurse managers should ensure a safe and supportive workplace environment. The negative attitudes and behaviours, bullying and insubordination among nursing staff should be acknowledged and addressed as they may hamper the easy adjustment of newly qualified registered nurses (R.683). Although less stress is a form of motivating newly qualified registered nurses (R.683) to acquire more knowledge and skills to independently manage challenging situations in the unit, newly qualified registered nurses (R.683) deserve to be supported to gain confidence in their performance.
Contribution/value-add: Newly qualified registered nurses felt overwhelmed and stressed during their adaptation stage, especially when they were left to run units by themselves with little managerial skills. As newly qualified registered nurses (R.683) should learn unit management through accepting responsibility and accountability, managing unit prematurely to gain self-confidence to practise as an autonomous competent nurse practitioner.
Keywords: experiences; newly qualified registered nurses; public hospitals; workplace environment; bullying; insubordination; orientation; attitude; behaviour; nurse manager.
Introduction
Globally, workplace environment is regarded as an important issue of concern in attracting and retaining registered nurses in healthcare workforce (Heidari et al., 2017; Van Bogaert et al., 2009) and is well documented. The workplace environment in nursing, particularly in public hospitals, is regarded as a complex environment to practise in (Boaretto et al., 2016; Elbejjani et al., 2020). The study conducted by Hall (2004) affirmed that a stressful workplace environment often occurred in public hospitals. The nursing workplace environment in public hospitals is not only stressful but also observed as unsupportive (Hall, 2004), thus leading nurses to be stressed. Unsupportive workplace environment demotivates nurses and thus they disengage themselves from performing their duties because of job dissatisfaction (Hegazy et al., 2021). However, nursing workplace environment that supports nursing staff in professional practice leads to high positive outcomes for both patients and nurses (Heidari et al., 2017).
This is the workplace where nurses perform their daily activities and experience extreme pressure based on the nature of their work. Hence, Damschroder et al. (2009) described nursing workplace environment as the inner setting of the organisation where nurses interact with the environment within which they perform their activities. Nursing workplace environment differs from one hospital to another; the dissimilarity grounded on nursing staff’s perceptions of their specific work-related interactions and environment (Lephoko et al., 2006).
There are factors in the workplace environment that may enable or hinder professional nursing practice. Moreover, Lake (2002) described nursing workplace environment as ‘organisational characteristics of a work setting that facilitate or constrain professional nursing practice’. Workplace environmental factors as perceived by Edem et al. (2017) are employees’ safety and job security, poor orientation in the new role, collegial working relationship among employees, feedback and acknowledgement for work well done, work engagement in decision making, and problem solving within the organisation (Ibrahim & Fadlalmola, 2020).
Although newly qualified registered nurses (NQRNs) enter the nursing practice environment with fluctuating feelings of delight of being a graduate coupled with fear of making mistakes because of limited clinical skills (Diaz et al., 2023). Today’s NQRNs enter a chaotic workplace environment attributed to inadequate staffing, insufficient resources, unchallenging jobs, high patient acuity, a lack of staff development, heavy workload, poor interpersonal relationship between nurse and colleagues, lack of managerial support and feedback (Alzahrani, 2022; Conradie et al., 2017, Lephoko et al., 2006). These factors have negative effect on the nursing workplace environment (Ramiah, 2020). The nursing workplace environment not only influences staff factors such as satisfaction and turnover but also affects the capacity to provide high-quality and safe patient care (Rathert et al., 2009).
Literature revealed attributes of workplace environment as associated with patient outcomes and nurses’ outcome. Workplace environment has an impact on staff both positively and negatively (Bakhtiyari, 2020). Nurses who perceive their workplace environment to be positive are motivated to perform their duties satisfactorily and thus reduce their intent to quit the job and enhance patient quality care (McHugh et al., 2016). Staffing nursing units with increased rate of registered nurses is perceived as a predictor of nurse recruitment and retention strategy (Balsanelli & Cunha, 2013; Edem et al., 2017; Stimpfel et al., 2014). In nursing profession, workplace environment is acknowledged as a crucial predictor of work-related outcomes, such as high safe and quality care, and decreased intent to abandon the job (Huang et al., 2020).
Nursing profession is globally regarded a high risk, stressful and burdensome profession given the fast-paced workplace environment with extreme job-demands (Lim et al., 2022; Luan et al., 2017). Thapa et al. (2022) describe job demands as organisational attributes that require physical and psychological efforts, which may lead to burnout. Stressful circumstances in nursing are related to the demanding work and responsible employee life (Nemec & Čuček Trifkovic, 2017). Nurses as forefront providers of patient care, their ability to render quality health service is determined by workplace environment (De Brouwer, 2019). Workplace environmental aspects such as emotional and psychological demands are linked to high risk for developing emotional exhaustion, whereas support in the workplace environment counteract emotional exhaustion (Hassard et al., 2017; Thapa et al., 2022).
Although there is a challenge of retaining nurses in the healthcare sector (Heidari et al., 2017) due to shortage of staff and workload, NQRNs require supervisors support to enhance their job performance. The degree of NQRNs’ involvement in professional practice is crucial to quality patient outcomes (De Brouwer, 2019). This can be counteracted by establishing a positive workplace environment for nurses with detailed workplace processes and collegial relationships to enhance nurse job satisfaction, productivity, quality of patient care and lower turnover rate (Lorber & Savič, 2012; Smokrović et al., 2022), and thus less stress.
Studies have investigated the effect of physical workplace environment on employees’ job satisfaction, performance, and well-being (Bakhtiyari, 2020). Some studies investigated nurses’ workplace environments and their impact on nurses’ and patients’ outcomes (De Brouwer, 2019). However, little research has been conducted to explore the experience of NQRNs (R.683) of workplace environment in their first 18 months of employment. Nowadays, nursing workplace environment plays a crucial role in nurses’ productivity. Hence, it is vital for nurse managers to understand the experience of workplace environment by NQRNs in their first 18 months of employment. The understanding of NQRNs experiences will help nurse managers to devise support strategies to deal with negative factors of workplace environment in nursing.
Most studies unveiled that most employees abandon their institution because of poor relationship with their immediate supervisors (Edem et al., 2017). Collegial supportive workplace environment in nursing is a core indicator of organisational support for NQRNs (Hegazy et al. 2021). For NQRNs to have less stress and be retained, a conducive nursing workplace environment under the support of good leadership is desired (Johnson et al., 2018). The studies by Al-Hamdan et al. (2016) and Edem et al. (2017) revealed that nursing workplace collegial relationships were linked to intent to stay decisions.
A positive supportive workplace environment in nursing is attributed to harmonious relationship between nurses and doctors as well as nurse and colleagues, adequate staffing, and managerial support. Stalpers et al. (2016) in their study concluded that adequate staffing was found to be the predictor of rendering high quality nursing care. A nursing workplace environment with adequate human resources augment remarkable nursing care (Stimpfel et al., 2014).
Therefore, working in a positive workplace environment is healthy because nurses are stimulated to think critically and are actively involved in decision making and problem solving within their practice setting. Nurses who feel empowered and recognised are motivated to perform their duties excitedly and thus enhance quality patient care and job satisfaction (Balsanelli & Cunha, 2013). Ferguson and Cioffi (2011) in their study findings concluded that positive workplace environment contribute in enhancing staff morale and quality patient outcomes. Furthermore, there will be low attrition rate, low patient accident and complaints, thus high productivity (Hegazy et al., 2021). A South African study by Rijamampianina (2015) reported that a supportive positive environment yields positive outcomes for the organisation because motivated employees are eager to provide quality care.
Contrarily, a negative workplace environment in nursing comprised aspects that make it difficult for nurses to perform their duties. Insuffiecient monetary or non-monetary reward (praise), poor colleagial relationships, lack of performance feedback, role ambiguity, inadequate human and material resources, exaggerated expectations from supervisors and peers as well as lack of managerial support (Bakhtiyari, 2020), demotivate NQRNs and thus lowers their performance.
A lack of involvement in organisational goal setting lead to disengagement because NQRNs feel they do not own the set goals as they were not part of it. Therefore, initiating a meeting and involving NQRNs in goal setting enhance their performance to attain co-set goals (Bkhtiyari, 2020). Poor recognition for work performed demotivates NQRNs and thus lower their performance. Hence, supervisors or nurse managers should acknowledge the work performed by their subordinates and give praise where it is due, not just specifically monetary rewards based on agreed interests.
Negative workplace relationships with colleagues through bullying and verbal abuse result in hostile workplace environment (Johnson et al., 2018), which may cause physical illness, emotional distress or mental stress (Havaei et al., 2021; Zangaro & Soeken, 2007; Zhou et al., 2015). Furthermore, the study by Edem et al. (2017) revealed that 84% of health workers perceived immediate supervisor support as stimulator to perform better.
A lack of feedback demoralises NQRNs as they will not know if their performance need improvements or to be maintained. Therefore, supervisors should give regular feedback on employees’ performance both positive and negative to enhance improvements where need arises (Bakhtiyari, 2020).
Unclear role for NQRNs causes frustration and retards performance. Hence, NQRNs should be provided with clear job descriptions and job specifications with reasonable expectations based on their knowledge and skills to perform assigned duties competently (Bakhtiyari, 2020).
Although the healthcare system is ever-changing, the demands for nurses remain unchanged. Globally, it is noticed that nurses comprise the largest percentage of the health workforce (Hegazy et al., 2021; Hung et al., 2018; Ibrahim & Fadlalmola, 2020; Rispel, 2015). However, because of ageing, majority of experienced registered nurses are leaving the healthcare sector, and the high number of NQRNs are entering the workforce to replace them (Laschinger et al., 2015).
The ageing population, chronic illnesses, and prolonged hospitalisation of patients have created an alarming escalation in the demand for nursing services (Rose, 1982). Hence, there is continuous demand for nurses in the healthcare system. In the study conducted in India, the Joumard & Kumar (2015) reported that worldwide countries are confronted by tremendous growth of healthcare needs, compounded by declining number of nursing professionals. The study conducted by Tamata and Mohammadnezhad (2022) acknowledged that nursing is a profession providing essential health care services worldwide and reported inconsistency in the supply of nurses to meet the increased demand of health services. Therefore, cohort of NQRNs (R.683) are employed to handle various demands in healthcare.
Despite NQRNs’ (R.683) previous enrolled experience, re-entry into the workplace environment is overwhelming and stressful (Bjerknes & Bjork, 2012; Feng & Tsai, 2012; Halpin et al., 2017). Martin et al. (2020) maintain that entering the healthcare workforce where independent practice is expected produces a feeling of stress and uncertainty (Wall, 2016). Majority of NQRN experience stress because of their inability to meet the job demands based on their appraisal of the available intrinsic resources to control the situation (Mtegha et al., 2022).
Studies on NQRNs’ conversion to practice reveal that an unsupportive workplace culture is a recurring challenge in public hospitals predisposing NQRNs to be bulled (Daws et al., 2020; Wong et al., 2018). Although the workplace environment is regarded as complex and interactive in nature (Kramer et al., 2011) improvement of NQRNs’ support is the best approach in retaining nurses and thus enhances performance resulting to quality patient care. It is acknowledged that nurses are carers; however, while rendering care for healthcare users (patients), nurses neglect taking care for their colleagues (Hawkins et al., 2019). Nurses who are not taken care of in the beginning of their professional journey, perceive the workplace environment to be threatening (Çamveren et al., 2020). Conversely, the workplace environments that are employee friendly are associated with job satisfaction, less stress and intent to abandon the nursing profession (Hugh et al., 2018).
The negative workplace environment has effects not only on NQRNs but also the nursing profession, organisation, and the patient (Hawkins et al., 2019). Within the healthcare workforce, NQRNs are the most vulnerable to negative workplace environment (Chang & Cho, 2016; Rush et al., 2014). This is reportedly because of their previous experience in nursing (Gallegher, 2012) and the unrealistic self, peer, and managers’ expectations for NQRNs to cope and perform nursing activities with ease (Gallagher, 2012; Rapley et al., 2006). Despite NQRNs (R.683) being in possession of previous nursing experience, in a hospital environment they encounter a change of identity, taking new responsibilities, accountability and independence to practise (Houghton, 2014; Mtegha et al., 2022), thus causing them to be overwhelmed and stressed (Hallaran et al., 2022).
Although negative workplace environment has been addressed in several studies in nursing, it is still a burning issue in the nursing profession. Literature has provided information on the impact of inadequate support on NQRNs and the reason for some of the NQRNs abandoning the nursing profession while others proceeding in the ‘mist of the storm’ without quitting despite the challenges of workplace environment. In addition, NQRNs who enter workplace environment are globally significant for the nursing profession, healthcare sector, and provision of quality patient care (Halpin et al., 2017).
Moustaka and Constantinidis (2010) in their study reported that negative relationships among fellow workers, and lack of social support from both peers and supervisors could contribute to the development of stress. Consequently, a negative workplace environment has negative impact on the well-being of NQRNs. Hussein (2018) stated that prolonged stress can lead to burnout, illness, absenteeism, attrition, job dissatisfaction, and decreased performance. These outcomes affect the organisation too, because NQRNs will be absent and may decide to quit the job, which in turn may affect safety of the patient and quality patient care (Boaretto et al., 2016).
Much has been documented about challenges experienced by NQRNs in their first year of employment, yet not much has been revealed from the view of NQRNs (R.683) who upgraded from enrolled nursing about their workplace environment experience in their first 18 months of employment.
Therefore, the objective of this study is to explore and describe experiences of workplace environment by NQRNs (R.683) in their first 18 months of employment in selected hospitals of Limpopo province, South Africa. It is vital for nurse managers to understand the experiences of NQRNs (R.683) workplace environment in the selected hospitals of Limpopo province, in order to devise strategies to manage negative workplace environmental factors if any experienced.
Research methods and design
A qualitative study that was exploratory, descriptive, and contextual was employed (Polit & Beck, 2017) to obtain rich information regarding experiences by NQRNs (R.683) for the first 18 months period of their employment in the new role. This approach enabled the researcher to gain an in-depth understanding of the phenomenon. Furthermore, it provided an opportunity to probe and observe non-verbal cues from participants.
The study population comprised 51 NQRNs (R.683) in their first 18 months working experience as registered nurses from six selected hospitals. A non-probability purposive sampling technique was employed to select NQRNs (R.683) working in any nursing unit in selected public hospital, who were registered with the South African Nursing Council, and in their first 18 months working experience as a registered nurse. Six public hospitals in two different districts of Limpopo province were purposively selected as majority of NQRNs (R.683) were practising in those institutions.
Data collection
Data collection is a process of gathering of information to address a research problem (Polit & Beck, 2012).
Data were collected using an audiotape; seven focus groups were interviewed, with members ranging from 4 to 6 participants. Unstructured face-to-face focus group interview was used to collect data. One guiding question was used to open the discussion, namely: ‘Can you tell me how do you experience your workplace environment’. Probing questions emanated from the interview data. Data collection began in May 2019 and ended in August 2019. Three focus group interviews were held in boardrooms, two in consultation rooms, and two in study rooms during participants’ lunch time as was convenient to them. Each focus group interview lasted between 30 and 45 min. The focus group interviews were conducted by the researcher in English and local languages Xitsonga and Tshivenda to increase understanding and probing in order to get rich information of data from participants. The point of data saturation was reached after interviewing the fifth focus group, two more focus groups were interviewed to check if there was any new information to come.
Data analysis
Data were analysed through thematic analysis (Braun & Clarke, 2006). Audio recordings were listened to repeatedly and then transcribed verbatim to be familiar with the content. The researcher read each transcript independently and assigned codes to identify distinct themes. The researcher also added the field notes to augment the data, which were repeatedly read. Similar information from each focus group interview was highlighted with similar colour and compared along all seven focus groups. Abstract labels were assigned to these concepts and gradually a coding framework evolved, which enabled mapping out the range and extent of views expressed by participants. One theme emerged, and an inductive process was used to derive five subthemes from the main theme.
Trustworthiness
Trustworthiness was ensured through acknowledgement of the following criteria: credibility, dependability, confirmability, and transferability (Lincoln & Guba 1985).
Credibility ensures that the study measures what it was intended to measure and truly reflects the participants’ social realities (Maher et al., 2018). Credibility was ensured through prolonged engagement by spending sufficient time building rapport while interacting with participants at the study site. Triangulation of data was reached using focus group interviews with participants from different selected hospitals in two different districts. An independent coder was used to verify data against the emerged themes. Member checking was achieved through paraphrasing during focus interview and feedback to participants to affirm the interpretation of data. Dependability refers to the research findings and methodology’s stability over time and conditions (Maher et al., 2018). To enhance dependability, detailed methodology was reported to enhance future researchers to trace the extent to which research processes had been followed. Confirmability is comparable to objectivity in quantitative studies (Maher et al., 2018). To enhance confirmability, field notes, audio recordings, and transcripts were kept safe as evidence for reference purpose. The researcher also used bracketing to set aside any preconceived ideas about the phenomenon under study. Transferability refers to the capability to transfer the study’s findings to other settings and contexts using the same methods (Maher et al., 2018). Transferability was ensured using purposive sampling where only NQRNs (R.683) within their first 18 months of entry into the new role were selected to be study participants. Furthermore, a dense description of the study’s findings was performed for the applicability of the findings in other similar contexts.
Ethical considerations
Ethical clearance was obtained from the University of Venda Research Ethics Committee with Ethical Clearance number: SHS/19/PDC/05/0104. Permission to conduct the study was sought from Limpopo Provincial Department of Health, which was duly provided. Furthermore, permissions were requested from Mopani and Vhembe District Executive Managers and from the Chief Executive Officers of the respective hospitals, which were granted. The system hierarchy was upheld for gaining permission to conduct the study. Consent was obtained from participants to show their willingness to participate in the study. All participants were requested to read the information sheet provided to be well informed about the purpose and the study details. The participants were assured that participation was voluntary and that they could withdraw from the study any time they like. Confidentiality and anonymity were guaranteed by identifying all participants alphanumerically, for example, P1 (participant 1) and ensuring that obtained data will be shared anonymously for research report purpose.
Results
One main theme and five subthemes emerged from the focus group interviews with NQRNs (R.683) (Table 1).
| TABLE 1: Findings of experiences of NQRNs (R.683) regarding negative workplace environment in the selected hospitals of Limpopo province. |
Focus group and participants were numbered as Focus Group 1 to 7 (FG1–FG7) and Participants as 1 to 10 (P1–P10).
Biographic information
Of the 51 participants, 47 (92%) were females and 4 (8%) were males. Therefore, it is evident that most participants in this study were females and, traditionally, nursing is regarded as a female dominated profession, which continues to date (Haigh, 2015). Achora (2016) affirms that nursing is still perceived as a female dominated profession.
Discussion of the findings of the focus group interviews held with NQRNs (R.683)
Theme 1: Negative workplace environment
A negative work environment can lead to diminished performance and poor employee morale. It may also increase turnover and absenteeism. Job burnout, a contributing factor to workplace negativity, may cause anxiety, stress, depression, and physical symptoms, such as migraines and muscle pain. These problems can impair work performance and result in adverse job outcomes.
Sub-theme 1.1: Negative attitudes and behaviour in the workplace
Negative attitudes are dangerous elements in the workplace, they can spread and affect everyone’s performance. The participants expressed their concerns in this manner:
‘[… W]hen you are newly qualified registered nurse, there is this attitude that you are new and is like a game sort of according to me, that you are new you don’t know anything. So, from the supervisor to the juniors they want to see what mistake you are about to do.’ (FG4, P6, Female)
Another participant said:
‘Sometimes when you ask questions, they just look at you with disgust as if you know it all, they are not willing to assist, insinuating that you are also a professional nurse … Mmmm.’ (FG7, P2, Female)
Another participant reiterated that:
‘Now that she is a professional nurse, she thinks she is better or advanced, … ha nursing care is nursing care we are all here to work.’ (FG3, P2, Female)
It is evident that NQRNs experienced negative attitudes from senior to lower categories they worked with during their first year of employment. Although NQRNs (R.683) were familiar with workplace environment as they worked in those units as enrolled nurses, they were sensitive to those who treated them with contempt. Newly qualified registered muses (R.683) in this study experienced an unfriendly and unwelcoming workplace, coupled with appalling staff attitudes, and professional jealousy by some members of the staff.
Layne et al. (2019), in their study on negative behaviours of healthcare professionals, concurred that participants reported experiences of rude behaviour, job stress, and the seriousness of negative behaviours. Rolt (2020) reported that participants experienced negative attitudes from some established staff, although they had identified the benefits of informal and formal support. Hawkins et al. (2022), Keil and Ward (2020), and Çamveren et al. (2020) reported 30% prevalence of exposure to negative workplace behaviour among nurses, which could increase attrition rate (An et al., 2022) and lower performance. The coping strategy chosen by NQRNs (R.683) when faced with negative workplace behaviour was often influenced by their coping resources (Callaghan et al., 2000). The fact that they did not opt to leave the workplace means that they had control over the situation.
A welcoming and supportive atmosphere should be established for NQRNs (R.683) to ensure a successful workforce as these encourage employees to perform to their highest ability. A stressful working environment and a precarious atmosphere create a breeding place for workplace bullying.
Sub-theme 1.2: Workplace bullying
Workplace bullying among healthcare workers has become a persistent phenomenon within organisations and has particularly increased in the health and community care sectors and that such behaviour is four times more prevalent in this sector than sexual harassment. Participants in the study indicated how they experienced bullying by being placed prematurely to lead the nursing unit with huge workload resulting to making mistakes. This study participants interpreted bullying as being assigned extra work, blamed and yelled at during discussions. This is how one of the participant expressed her feelings:
‘Due to the workload that we are … working alone and doing everything alone you find that maybe you, forgot to write something and whenever it is discussed they blame you and shout at you.’ (FG3, P2, Female)
Sonmez and Yildirim (2016) reported that 32.4% of nurses were intentionally assigned huge workload without assistance, resulting to NQRNs feeling stressed and difficult to adapt to the new role. Similarly, Hawkins et al. (2020) in their study reported that 78% of the participants referred work-related bullying to being given excessive workload. Too much work was regarded as one of the sources of stress (Callaghan et al., 2000). Hussein et al. (2017), in their study of newcomer perceptions of transitional support in a clinical speciality, reported that some new graduates felt they were being ‘set up to fail’ and felt deflated by lack of clinical support. Brunworth (2015) affirms that a bullied nurse tends to make mistakes.
A heartbroken participant added:
‘Someone will be expecting you to do a mistake to the client so that you get reported so that you are out of work. This is how bad it is when you are newly qualified nurse.’ (FG4, P6, Female)
The findings of this study concur with Sonmez and Yildirim’s (2016) findings that participants felt they were spied on to catch their shortfalls. Bullying of NQRNs (R.683) may not only affect them but the hospital as well thus compromising quality patient care (Rust, 2018). Newly qualified registered nurses (R.683) as victims of bullying are being denied an opportunity to be orientated with the anticipation that they are familiar with the culture of nursing.
The participant further indicated that:
‘You are sometimes called names such as “magradu” or “mafresher” which literally means newly qualified fresh men.’ (FG4, P6, Female)
Al Omar et al. (2019) indicate that verbal bullying involves the use of offensive words through teasing, name-humiliating, and dehumanising a person in public that manifests into a toxic or hostile work environment, which compromises quality of care and patient safety. Furthermore, the authors agree that bullying inhibits teamwork, obstructs communication, disrupts behaviour, and increases medical errors by affecting the quality of healthcare organisation. Shetgiri (2013) also categorises bullying as shouting at someone even in the presence of others and gossiping.
Sub-theme 1.3: Lack of orientation
Orientation could be defined as time set to familiarise NQRNs to their workplace environment, staff, protocols, policies, and procedures as well as to their job description (Innes & Calleja, 2018).
The study’s findings reveal that orientation was performed but not to the satisfaction of all participants because the focus was mostly on the environment.
One of the participant commented:
‘They concentrate more on ward environment orientation than on what we are supposed to do.’ (FG3, P2, Female)
Tembo et al. (2019) and Thopola et al. (2013). revealed that NQRNs felt that they had inadequate orientation as they were only showed the layout of the ward. Scheepers (2020) reported that some senior nurses are just reluctant to orientate NQRNs.
The assumption that the NQRNs (R683) were already socialised into the healthcare environment, and that they could adjust into a new role with ease has a negative impact as NQRNs (R.683) acknowledged uncertainty of the nature and values of the new role (Walker et al., 2016) and fear of unknown in the new role (Roziers et al., 2014).
Another participant had this to say:
‘As a newly-qualified registered nurse as we are coming from school some of the things you are not aware of in the ward …’ (FG4, P4, Female)
Furthermore, the discourse of ‘hitting the floor running’ is becoming increasingly vociferous where NQRNs are expected to enter the workplace ready to practise a new role post-graduation (El Haddad et al., 2017).
Moreover, findings revealed how majority of NQRNs (R.683) were expected to be practise-ready without any orientation in the new role.
Participants verbalised with disappointment:
‘They don’t orientate us. After completion of our course, they don’t have time to orientate us … they said you have graduated, you are supposed to know everything.’ (FG1, P3, Female).
‘They didn’t orientate us, they thought as I was working there, I just know all the things at the end of the day I just want to ask everything.’ (FG3, P7, Female).
‘They don’t give us support; they don’t orientate us. So, you find that Eeh when you come from school you do work alone.’ (FG4, P9, Female).
The findings concur with Missen et al. (2015) who reported that the majority of NQRNs who had previously worked as enrolled nurses struggled with role transition, which is difficult and stressful. Cubit and Lopez (2012) confirmed that NQRNs with previous enrolled nurse experience did not automatically ‘hit the floor running’, especially when left alone to run the unit without the required support throughout their graduate nurse journey. The authors further indicated that NQRNs who had previously practised as enrolled nurses preferred to conceal their previous nursing experience, because they feared being treated by their nurse supervisors as already capable of practicing as registered nurses. However, newly qualified registered nurses (R.683) in this study did not conceal their previous enrolled nurse experience because in South Africa entry to bridging course leading to registration as general nurse prior enrolled nurse experience is a pre-requisite (SANC, 1989). Therefore, NQRNs (R.683) need ongoing support like any other NQRNs (Cubit & Lopez, 2012). However, Thopola et al. (2013) suggest that a lack of orientation to NQRNs (R.683) post-graduation could be because of shortage of staff.
Sub-theme 1.4: Shortage of staff
Shortage of staff is a global concern, and when coupled with workload it has been cited to be the principal cause of stress in the nursing profession (Mutisya, 2019).
A participant expressed her frustrations as follows:
‘I’m working the duties for staff nurses and the duties for professional nurses but without any support.’ (FG1, P3, Female).
Another participant added:
‘Immediately when you pass when we got in the unit they give us professional nurses work [or] duties … seemingly is just like there are no more staff nurses … they are shortened because everybody is being trained. So, you will find out that you are having burdened by the duties … So, to us when we reach home we are damnely tired because we are working from assistant work, staff nurse to professional nurse duties being alone.’ (FG1, P1, Female)
Scheepers (2020) and Esmaeili et al. (2015) reported that a nursing shortage increases the nursing workloads. The shortage of experienced registered nurses is noticed as an obstacle in rendering quality care as well as having negative impact in supporting NQRNs (Mabelane et al., 2016). Furthermore, participants in the study conducted by Nkoane and Mavhadu-Mudzusi (2020) complained of excessive shortage of staff, particularly staff nurse categories (enrolled nurses) resulting in a high workload. Consistent to this study, most participants blamed shortage of staff for their seniors’ inability to support them within their 18 months of entry to the new registered nurse role.
Another participant highlighted the role confusion during staff shortages as follows:
‘I was working in maternity ward, I was a newly-qualified professional nurse, and sometimes there was a shortage in the ward while I was supposed to be left alone in the ward while I was not having midwifery.’ (FG7, P7, Female).
This is consistent with Cubit and Lopez (2012) who reported that one participant in their study said: [So, what worried me most was one day you were an Enrolled Nurse, the next day you’re a Registered Nurse and all of a sudden, you’re sort of in-charge. I thought … how am I going to know everything? How am I going to remember everything? So that frightens me a bit’].
This situation has a negative effect on participants’ physical and psychological well-being leading to increased stress level. Abiodun et al. (2019) revealed that nursing more patient than usual cause stress for NQRNs.
Furthermore, Kobe et al. (2020) indicated in their study that patient overload versus shortage of nurses was tiring for new graduate nurses. In this study, patient overload seemed to be stressful and exceeding NQRNs’ (R.683) ability to perform, especially as they used to nurse few patients under supervision, but now they are on their own with many patients.
One of the participant shared her frustrations regarding prioritisation of work schedule:
‘There is not enough time to do things correctly, when it comes to some of the duties, because of the shortage you must go and be hands on working on the patients and with the other duties to account like working with papers like admin staff to updates all things in the unit.’ (FG4, P6, Female)
Similar findings were revealed by Sönmez and Yildirim (2016) who reported that time shortage because of workload on account of shortage of staff and patient to nurse ratio causes inability for new graduates to spend enough time with patients, rushing tasks and fearing making mistakes because of hasty decisions and taking care of multiple patients and tasks at a time. Maakie (2006) affirmed that stressful tasks affected majority of the workforce annually.
Sub-theme 1.5: Insubordination of junior staff members
Insubordination could be defined as a tendency of undermining or belittling one’s senior by refusing to carry out assigned tasks or activities. Newly qualified registered nurses (R.683) in their first 18 months of professional practice experienced insubordination.
This is how the participants expressed a lack of cooperation from junior staff members:
‘[M]y age is very young, my juniors they are older than me …those junior nurses like assistant nurses when we want to send them to laboratory maybe you have to put up some blood they don’t want to take the specimens and send to the laboratory.’ (FG2, P3, Female)
‘The time that I wrote delegation, the junior nurse told me that on the delegation book you delegated me this … today why do you delegate me this? … and she was very cross.’ (FG2, P3, Female)
‘If I send someone to do the job … they undermine me especial the registered auxiliary nurses they don’t do things when I send them.’ (FG3, P4, Female)
‘The junior nurses when you delegate them, they will tell you that you went to school alone. So, you did not come here with the nurse …’ (FG7, P3, Female)
Ndaba (2013) reported that auxiliary nurses who had been in the institution for a long time, refused delegation of duties from newly qualified professional nurses. Nearly all participants in this study experienced being undermined and disrespected by their subordinates because of their age.
Likewise, Nkoane (2015) and Shongwe (2018) reported that newly appointed nurses experienced insubordination from older experienced nurses and nursing auxiliaries who were sometimes difficult to work with and even refused delegation. This resulted in NQRN feeling belittled and disrespected by their subordinates in their units and eventually negatively younger nurses commonly experience more stressors within the workplace (Sawafta et al., 2016). Thus, NQRNs (R.683) require comprehensive support for their physical and mental well-being.
Conclusion
The study’s findings, contribute to a better understanding of the experiences of workplace environment by NQRNs (R.683) in their first 18 months of employment in the new role in selected hospitals in Limpopo province. Despite being in possession of previous enrolled nurse experience, NQRNs (R.683) still face many challenges of negative workplace environment such as poor collegial relations and teamwork, bullying in the form of verbal harassment dire staff shortages related increased workload, poor orientation on tasks leading to stress, and inability to cope. Public health institutions should develop comprehensive strategies that can improve positive work environment realities, including staffing, rationing of workload, and team climate.
Acknowledgements
The researcher extends sincere thanks to the participants, nurse managers of hospitals, and the provincial health department for granting permission.
Competing interests
The authors have declared that no competing interest exists.
Authors’ contributions
T.S. designed the study, D.U.R. and K.G.N. supervised the conduct of the study, data collection, and analysis. T.S. and D.U.R. drafted the manuscript and all the authors reviewed and edited the final draft.
Funding information
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data availability
The datasets generated and/or analysed during this study are not publicly available because of the institutional rules and regulations. They are however, available from the corresponding author D.U.R., on reasonable request.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency, or that of the publisher. The authors are responsible for this article’s results, findings, and content.
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