Insufficiently supported in handling responsibility and demands: Findings from a qualitative study of newly graduated nurses

Abstract Aims and objectives To explore newly graduated registered nurses' experiences and how they manage complex patient situations. Background Newly graduated registered nurses' working in acute care hospital settings are challenged by managing complex patient situations in rapidly changing clinical contexts involving increased patient acuity, comorbidities and staffing shortages. Design Qualitative study design. Methods Data were collected using focus groups interviews of a total of 16 newly graduated registered nurses with clinical work experience of 6 months of direct patient care in an acute care hospital setting. Analyses were conducted using qualitative content analysis. COREQ reporting guidelines were used. Results The analysis resulted in the overarching theme “Not being sufficiently prepared and supported to meet responsibilities and demands.” The theme included three categories: “Responsibility is not in proportion to competence,” “Lack of medical competence and experience complicates patient safety” and “Strives for control to manage and organise nursing care.” Conclusion The results show that newly graduated registered nurses' are not sufficiently supported for the level of responsibility and the demands placed on them when providing nursing in complex patient situations in acute care hospital settings. If they are given sole responsibility for multiple complex patient situations, patient safety may be compromised. Relevance to practice Special attention need to be paid to NGRNs support to medical competence in the areas of assessing, planning, prioritizing, leading, and distributing nursing care in daily clinical settings for at least their first year of professional work.


| INTRODUC TI ON
Making newly graduated registered nurses (NGRNs) responsible for nursing in complex patient situations in acute care hospital settings is associated with increased patient acuity and deteriorating patient health. This is common as numbers of patients admitted to hospitals with comorbidities and multisystem disorder are increasing (Sturmberg & Lanham, 2014) due to the ageing population (Zwijsen, Nieuwenhuizen, Maarsingh, Depla, & Hertogh, 2016) and decreasing patient length of stay in hospitals (Buchan, O'may, & Dussault, 2013). Further, new medical interventions and technology are evolving at a higher rate than ever (Buchan et al., 2013).
There is also a shortage of registered nurses (RNs) (ICN, 2019;WHO, 2018) and in particular experienced RNs (National Board of Health & Welfare, 2015). Due to this, NGRNs are expected to provide a level of nursing care in complex patient situations similar to that expected of experienced RNs (Purling & King, 2012), despite reports of NGRNs finding providing adequate nursing care challenging (Gardiner & Sheen, 2016).

| BACKG ROU N D
The initial period in a RN's career can be a time of growth and development, but it can also be a time of vulnerability (Duchscher, 2009).
NGRNs have reported experiencing stress, anxiety, fear of failure and incompetence during their initial time as RNs (Arrowsmith, Lau-Walker, Norman, & Maben, 2016;Walton, Lindsay, Hales, & Rook, 2018). From the perspective of NGRNs, the assessment of patients' needs is fragmented (Benner, 2001). According to Benner's nursing theory, novice is characterised by NGRNs' difficulties in handling new situations due to a lack of experience (Benner, 2001). This means that NGRNs need regulations, such as task lists and clear guidelines, that can guide their decisions and actions regarding the provision of nursing care (Benner, 2001).
Advanced beginners have learned how to handle situations based on experience. The competent stage is obtained when an RN can handle a range of different situation. A proficient RN perceives situations holistically rather than in fragments and can perceive the significance of a situation as a whole. NGRNs defined themselves as novices or advanced beginners during their first two years of practice (Benner, 2001). Clinical competence in nursing is a holistic and dynamic process that requires individual characteristics such as motivation, critical thinking, experience, attitudes, pedagogical factors, knowledge, skills and functional tasks, which leads to overall competence in nursing (Calzone, Jenkins, Culp, Caskey, & Badzek, 2014;Curuso, Fida, Sili, & Arrigoni, 2016;Notarnicola et al., 2016;Pijl-Zieber, Barton, Konkin, Awosoga, & Caine, 2014).
Clinical competence in nursing practice is the ability to apply both theoretical and practical knowledge to perform a task with a desirable outcome under various clinical contextual conditions (Benner, 2001). Nursing in complex patient situations requires critical thinking skills in order to identify changes in patients' conditions so adequate nursing interventions can be made (Shoulders, Follett, & Eason, 2014).

The complexity of patient situations is specific and dynamic
where different factors interact with each other, related to different factors such as personal, social and clinical (Shippee, Shah, May, Mair, & Montori, 2012) as well as instability, variability and uncertainty (Huber, Kleinknecht-Dolf, Kugler, & Spirig, 2020). Instability refers to unexpected events such as sudden deterioration, variability is caused by different types of health problems, comorbidity and is influenced by age, and uncertainty is affected by the diversity of health problems the patient is experiencing, patient knowledge and patients' ability to manage their health conditions. These factors are further influenced by assessment and interventions that RNs are carrying out or are not carrying out. NGRNs may have difficulty recognising changes and deterioration in patients' conditions due to lacking a holistic approach (Purling & King, 2012). NGRNs have expressed that patients with multiple diagnoses were outside their scope of expertise, and patients who experience a sudden deterioration in their condition are challenging (Gellerstedt, Moquist, Roos, Bergkvist, & Craftman, 2019). Nursing interventions and decision-making processes in complex patient situations need to include professional judgement based on experience in addition to the use of nursing care plans and guidelines (Huber et al., 2020). In this study, nursing in complex patient situations refers to the instability, variability and uncertainty of a patient's medical treatment and everyday life, and this complexity is further increased by the nursing decisions and interventions provided. A shortage of RNs will have an impact on NGRNs as they will be challenged with new demands and responsibilities earlier and with reduced support from experienced RNs. In addition, clinical context where nursing care is carried out is What does this paper contribute to the wider global clinical community?
• Insufficient clinical competence in nursing care in complex patient patients situations among newly graduated registered nurses' (NGRNs) will threaten quality of care and patient safety. If NGRNs being made solely responsible for the nursing care of multiple complex situations is considered to compromise patient safety.
• Since the clinical competence of NGRNs is lacking in regard to take on the responsibility required in complex patient situations, introductory programmes, continuous competence development and collegial support are of crucial importance.
• NGRNs need the support of experienced RNs when working in complex patient situations. Special attention need to be paid to their medical competence in the areas of assessing, planning, prioritising, leading and distributing nursing care in daily clinical settings for at least their first year of professional work. changing rapidly (Lima, Newall, Kinney, Jordan, & Hamilton, 2014).
Further, research on NGRNs' competence in an increasingly complex healthcare system with acute care hospital settings is needed (Kleinknecht-Dolf et al., 2015). In order to provide high-quality care and increase patient safety in complex patient situations, it is important to understand how NGRNs experience and handle these situations. The aim of this study was to explore NGRNs' experiences and management of complex patient situations.

| ME THOD
This study has an inductive qualitative design to gain a deeper understanding of the participants´ experience of a phenomenon (Polit & Beck, 2021). Data were collected through focus group interviews (FGI). The FGIs were semistructured interactive discussions that can be used among participants sharing homogeneous experiences to explore their views and opinions and are suitable for gaining understanding into complex behaviours and motivations (Morgan, 1997). The participants answered questions individually, talked and interacted with each other, and the FGIs were designed to get insights, views and explore NGRNs experiences about how they manage nursing in complex patients' situations. COREQ was used as reporting guidelines (see File S1) in line with EQUATOR (Tong, Sainsbury, & Craig, 2007).

| Participants and setting
A total of 16 NGRNs voluntarily agreed to participate in the study, all 16 were female, and the age ranged from 22-33 years (mean age 24.6). A convenience sampling was used (Polit & Beck, 2021). Fiftytwo NGRNs employed by a county council at acute care hospitals in central Sweden participated in a mandatory clinical development programme organised by the county council held over twelve days in their first year of employment. At their first day of the clinical development programme, an introduction meeting was arranged and the NGRNs who were interested in participating in the study wrote down their contact details. Out of the 52, there were 20 NGRNs who reported interest to voluntary participate in the study, 18 of them confirmed thereafter via telephone that they wanted to participate in a FGI. Two participants were prevented from participating due to the time schedule did not work with the rest of the participants in the FGIs. The participants had six months of clinical work experience from direct patient care at different wards including medical, surgical, emergency, gynaecological, psychiatric and oncology wards.
Oral and written information about the study was given to NGRNs at the first meeting of this clinical development programme.

| Data collection
Data were collected through focus group interviews (FGI), as described by Morgan (1997 with five participants in one group, four in two groups and three in one group. The first author acted as a moderator during these interview sessions. An assistant moderator took notes and gave an oral summery at the conclusion of each interview. As a starting point for the discussion, participating NGRNs were asked to describe their understanding of nursing in complex patient situations in relation to instability, variability and uncertainty. The same semistructured interview guide was used in all four FGIs.
The interview guide contained a broad opening question: "Can you please tell us what it is like to be a newly graduated nurse?", followed by the key question: "Can you please tell us about your experience of nursing care in complex patient situations?" and "Can you please tell us about how you manage nursing care in complex patient situations?" Probing questions were used when needed, such as: "Can you please tell me more about that?". The interviews lasted for 62-75 min and were recorded and transcribed verbatim.

| Data analysis
Data were analysed with a text-driven, interpretive qualitative manifest and latent content analysis (Krippendorff, 2018). The interviews were read through repeatedly to reach an understanding of general substance and then read closely to identify manifest meaning units in each interview. The next step was to take out codes from the meaning units in each interview. Thereafter, the codes from all four interviews were used to generate subcategories based on similarities and differences, with the ability to trace each individual code back to the original text. In the next step, the subcategories were sorted into latent interpreted content in categories. Subcategories were built on manifest data, and thereafter, interpretations could be made, and the methodological process of going back and forth in the text to find different levels of abstraction to increase the ability to see context and patterns was followed (Krippendorff, 2018). From the categories, the latent content emerge represented in a theme. When the analyses were complete, the data were read in relation to the categories. The relevance of the result was finally verified by the correlation between the aim and the categories (Krippendorff, 2018). The first and second author coded two of the interviews independently, which resulted in high congruity. All authors took active part throughout every step in the analysis process. All steps in the analysis process were characterised by flexibility, verification of the original text and each step of the analysis were discussed within the research group, and any discrepancies were discussed until consensus was reached (Table 1).

| Ethical considerations
The study was given ethical approval by the Ethical Review Board.

| RE SULTS
One overarching theme, "Not being sufficiently prepared and supported to meet responsibilities and demands," and three categories emerged: "Responsibility is not in proportion to competence," "Lack of medical competence and experience complicates patient safety" and "Strives for control to manage and organise nursing care" (Table 1).

| Strives for control to manage and organise nursing care
Participants reported striving for control to manage and organise nursing care in complex patient situations, which dictates that the NGRNs meet patients and participate in their nursing care in order to build a picture of a patient's health status and needs. When the NGRNs were responsible for fewer patients in complex situations and they had control, they felt satisfied and stimulated. When they were responsible for several patients with complex situations, they found it hard to prioritise and described feeling insufficient and that there was never enough time. Reflecting with colleagues at the end of a shift gave the NGRNs the possibility to learn how to do nursing care in complex patients' situations in different ways. It also gave them the possibility to verify how they were thinking, how they handled various situations and to learn from their own and others' experiences.
Having someone to talk to and reflect… is really im-portant… to talk to someone who understands and you learn how to think and do… even if someone says "good work", you do well anyway… (quiet)… we reflect and then I usually say things like how the day has been and how to do differently… yes… we should do it every day but sometimes just a minute and sometimes you sit down for a while… but it's only on the day shifts… (P 1,2,4, FGI 2)

| D ISCUSS I ON
The aim of the study was to explore NGRNs' experiences and management of complex patient situations. Their experiences and management of complex patient situations can be understood as they are not sufficiently prepared and supported to meet responsibilities and demands as NGRNs.
The participating NGRNs experienced being given responsibilities beyond the scope of their professional competence in complex patient situations without support from experienced RNs. This was also the case when they had to take sole responsibility for the nursing care of several complex patient situations simultaneously. Walker, Costa, Foster, and de Bruin (2017) found that NGRNs' responsibilities in nursing care exceeded their competence. In addition, patients with comorbidities and sudden deterioration were described as challenging and beyond the level of NGRNs' competence (Gellerstedt et al., 2019). A further complexity is when NGRNs solely provide nursing care to patients, the risk of compromising patient safety increases (Murray-Parahi, DiGiacomo, Jackson, & Davidson, 2016). The limited experience of complex patients' situations among NGRNs (Benner, 2001) can result in them being given a level of responsibility that is too high for them to manage independently. NGRNs can experience complex patients' situations as being more complex due to being task oriented and having difficulties evaluating and prioritising what is important based on a holistic view of each patient's health (Benner, 2001). Hence, boundaries have been pushed over the last decade due to increased patient complexity-patients that previously were treated in intensive care units nowadays often receive care in general hospital settings (Massey, Aitken, & Chaboyer, 2009).
It is not surprising that the NGRNs participating in the present study experienced that they needed more support from experienced RNs in handling complex patient situations. Supportive colleagues and constructive feedback are vital for NGRNs in learning to cope with workplace responsibilities (Irwin, Bliss, & Poole, 2018;Lima, Jordan, Kinney, Hamilton, & Newall, 2016). It is, however, surprising and unsuitable for NGRNs to be expected to supervise the induction of other NGRNs after just 6 months of working experience and to be responsible for supervising nursing students' clinical education after even less time. ICN (2013) highlights that healthcare managers should not allow inexperienced NGRNs to practice beyond their level of competence due to concerns regarding patient safety.
In the present study, NGRNs reported a lack of medical competence in judging prescriptions, a fear of making mistakes and actually making mistakes. Medication errors are related to complex patient situations (Saintsing, Gibson, & Pennington, 2011), and NGRNs need further training to better understand the interactions between medications, side effects and the effect of medications on patients' health (Willman, Bjuresäter, & Nilsson, 2020a (Scott, Matthews, & Kirwan, 2014). In fact, person-centred care is important to patient safety, to assure that patients have the information and knowledge they need to act as an advocate for themselves (Bishop & Macdonald, 2017). The results show that the NGRNs' experiences challenge in the leadership and organisation of nursing care in complex patient situations. This is an important finding, and other recent statements (WHO, 2020) and studies presenting results on NGRNs' professional competence (Gardulf et al., 2019;Halabi, Lepp, & Nilsson, 2020;Nilsson et al., 2019) indicate a need to transform nursing education so it has a greater focus on competencies relating to leadership and the organisation of nursing care. These competencies are often taught during the latter part of nursing education programmes (Theander et al., 2016), which will not give nursing students the possibility to internalise theory and practice. Nursing education programmes need to pay more attention to rapidly changing healthcare contexts to prepare nursing students better of their transition into working life.
A lack of experienced RNs and high turnover seem to create a vicious circle as NGRNs participating in this study reported that some shifts were manned by only NGRN, making them solely responsible for several complex patient situations without any support from experienced RNs. When the level of nursing staff is low, quality of care and safety can be compromised, with a risk of substandard nursing care and patient mortality (Aiken et al., 2014;Ball et al., 2018). The main reason for RNs leaving the profession is poor working conditions (SCB, 2017) and unreasonable workloads (Aiken et al., 2012;Rudman & Gustavsson, 2012 and critical thinking is essential (Benner, 2001). Lifelong learning also improves competence (EU, 2013). Taking time to reflect is a dynamic process that involves gaining new perspectives to develop nursing (Davis, Taylor, & Reyes, 2014). In relation to competence development and lifelong learning, the results in this study show the importance of self-reflection as a way to further develop oneself, and this has also been shown in other studies (Forsman et al., 2019;Nilsson et al., 2019). Yet, the ability to think critically decreased after 9-15 months of clinical practice among NGRNs (Willman et al., 2020b). Possible reasons for a negative development in critical thinking include that NGRNs lack time for reflection, the lack of experienced RNs to support them and give new perspectives and the lack of possibilities for NGRNs to meet patients. This might reduce the opportunities for NGRNs to reflect on how to handle nursing care in complex patient situations.

| Strengths and limitations
The strength in FGIs described by Polit and Beck (2021) (Morgan, 1997), which also will contribute to achieve data saturation. In this study, data saturation was achieved after completing the analysis of the fourth FGI. Limitations to consider were also related to differences between the NGRNs' specialised work units in acute care hospital settings, which may have influenced the results in terms of their differences in experiences related to their reflections. Additional limitations that need to be considered in relation to the transferability of the result are due to the convenience sampling which did not include males, who might have other views and experiences than females. The first author has experience of nursing in complex patient situations, and this preunderstanding may have affected the analysis. Therefor, all authors discussed the preunderstanding thoroughly and have been involved in the analysis process. In addition, the manuscript has been critically discussed in research seminars including the authors and outside researchers on two occasions to accentuate the objectivity of the analysis.

| RELE VAN CE TO CLINI C AL PR AC TI CE
Insufficiency competence among NGRNs threatens quality of care and patient safety. NGRNs need support from experienced RNs, especially in regard to complex patient situations that demand more competence in the areas of medical competences, assessing, planning, prioritising, leading and distributing nursing care. A lack of control in managing and organising nursing care will negatively affect person-centred care. Since the foundation of the profession has not taken responsibility for complex patient situations, this means that introductory programmes, continuous competence development and collegial support are of crucial importance.

ACK N OWLED G EM ENTS
We are grateful and want to thank all the newly graduated registered nurses participating in this study in the beginning of their careers.

CO N FLI C T O F I NTE R E S T
The authors declare that they have no conflict of interests.