Objective: To explore the experiences of new nursing graduates during their internship in a tertiary care setting.
Method: The qualitative phenomenological descriptive study was conducted from September2020 to May2021 at three private hospitals of Peshawar, Pakistan, namely the Kuwait Teaching Hospital, the Mercy Teaching Hospital and the Prime Teaching Hospital. New nursing graduates of either gender were enrolled. Data was collected through semi-structured interviews using an interview guide and probing questions. Data was analysed using the 6-step Braun and Clarke method.
Results: Of the11 subjects, 6(54.5%) were males and 5(45.5%) were females. Data led to the generation of four main themes; challenges, coping strategies, improved knowledge, and need for improvement in internship programme. The participants said certain types of individuals and organisational challenges affected them both personally and socially in their daily routines. Coping strategies varied among the subjects.
Conclusion: New nursing graduates faced both individual and organisational challenges which is a matter of concern. Policies and their proper implementation should be planned to counter such challenges.
Nurses are the most important members in the healthcare team, consisting of half of the human recourses around the world with a vital role in providing competency-based care to patients.1 In spite of being a highly demanding profession, according to the World Health Organization (WHO), the human recourse in the nursing profession is below the required standards even though the numbers will approximately touch 12.9 million by 2035.2 In a developed country, like the United States, the shortage of registered nurse was estimated to be 340,000 by 2020.3 A government report says Pakistan needs approximately 60,000 new nursing graduates(NNGs) to deliver their services in the current healthcare system.4
Interns are NNGs from university and enrolled in the internship programme during the first year of professional career.5 The internship phase is the period during which NNGs grasps and adjust themselves to the complex healthcare system and the demanding career in terms of both personnel and professional life.6 Orientation is the phase of internship programme in which NNGs are introduced into the organisation which is critical for the provision of quality care to the patients.7 The internship process is stressful for NNGs, causing both interpersonal and intrapersonal anxiety.8 An Australian study in 2017 explained that healthcare systems around the world are becoming complex, causing problems to NNGs in different forms, such as clinical, social and emotional.9 The academic performance of nursing graduates affects their career, family and even society.10 A study showed that NNG were not prepared up to the level where they could provide holistic care to the patients.11 In addition, NNGs are mostly unprepared and unaware of certain areas in clinical practice, such as managing critically ill patients and utilising modern medical equipment.12 The current study was planned to document the experiences of NNGs during their internship in a tertiary care setting.
Subjects and Methods
The qualitative phenomenological descriptive study was conducted from September 2020 to May 2021 at three private hospitals in Peshawar, Pakistan, namely, the Kuwait Teaching Hospital (KTH), the Mercy Teaching Hospital (MTH) and the Prime Teaching Hospital (PTH), having a cumulative capacity of around 300 beds. After approval from institutional ethics review committee (ERC) of Prime Foundation Pakistan (Prime/IRB/2020-247) and the sample was raised using non-probability purposive sampling technique at Rufaidah Nursing College, Peshawar; attached with three mentioned hospitals for clinical purpose. Those included were nurses of either gender with at least three months of exposure as an intern who could speak Urdu and English. Those not willing to participate, on leave, or terminally ill were excluded.
After taking informed consent from the subjects, data was collected using a semi-structured interview guide along with probing questions which were approved by one assistant professor and two nursing lecturers. The interviews were conducted individually face-to-face, and each one lasted 30-60 minutes. Non-verbal expressions were noted throughout the interview process. The sampling process was continued till data saturation which occurred on tenth interview, while one more participant was interviewed to ensure the quality. The audio-recorded interviews were transcribed and translated from Urdu to English. Efforts were made to ensure meaning and interpretation according to the participants’ experiences in the form of words.
Data was analysed using the 6-step Braun and Clarke method.13 Subsequently, codes, categories and themes were generated. The analysed data was checked thoroughly multiple times for any errors and omissions.
Of the11 subjects, 6(54.5%) were males and 5(45.5%) were females. Data led to the generation of four main themes; challenges, coping strategies, improved knowledge, and need for improvement in internship programme. Each theme had 6 categories (Table).
Under the firs theme ‘Challenges’, multiple challenges were reported that affectedthe NNGs in different aspects.
The first category was ‘Personnel Problems’. The participants viewed personal weaknesses, such as feeling difficult, lack of clinical experience and low morale. Most of the participants shared that they were very uncertain during the initial days of internship and felt pressure both physically and mentally. One participant said, “…I was confused, nervous and frightened at the start of internship and the first three days…physically I was overburdened and there was a lot of pressure mentally…the attendants were very annoying.” As novice learners, a participant said, “…first months of internship were very difficult due to hesitation because of no experience and instructions from seniors…we were just alone in the learning process…” Interference in personal life was reported by the participants. “…our seniors were targeting our personal life, such as dressing and scarf, rather than practical skills, and these things frustrated us a lot…”
One participant expressed thoughts about salary package. “…it is injustice that we do our internship on such a low amount of money… it should be the same as other registered nurses…I mean, this is a very cruel act…very cruel indeed…”
The second category was ‘Social Problems’. Some of the participants viewed issues related to society that were very frustrating and embarrassing. Most of the participants experienced that they were not accepted as qualified healthcare professionals by society. As a participant described, “…you cannot make them understand what is the value of the nursing profession in Pakistan … we are just known for administering injections no matter how much we study and care for them…” The participants also shared that they were ‘tortured’ by patients and their attendants. As a participant reflected, “…in the wards people call you with different names, like “ babosiab” (compounder), but don’t take your name, and some call ‘nurse’ in a funny and joking style and laugh at us …” Some of the participants intended to leave the profession due to such social pressure. One of the participants said, “…I am thinking to join teaching as a primary government teacher or get settled abroad …”
The third category was ‘Lack of Education among Seniors’. As per experiences of the NNGs, most seniors were having low qualification which was the main reason for creating problems in achieving internship goals. As one of the participants said, “…the main problem is that the in-charges are mostly technicians with two-year diploma, creating many problems for us…we are just stuck due to our degree.”
The fourth category was ‘Lack of Cooperation and Professionalism’. The participants had to face autocracy, resistance, backbiting, high expectations, gender discrimination and lack of support. As one of the participants expressed, “…the senior nurses and head nurses were not cooperative…they do not care…” Another participant quoted said, “…our supervisor had qualification of a technician and was very rude … they also made complaints against us at college and hospital so that we can be demoralised ...”
Most of the male participants said they were totally discriminated against. As one of the participants said, “…they say nothing to us and maintain silence, but when female internees arrive, they become so happy and attentive… Some magic happens…they avoid male students…”
The fifth category was ‘Lack of Support from College’. Most participants shared that the communication between college and hospital was unsatisfactory. One of the participants said, “…the teachers were not in contact with the hospital and there was no clinical instructor during the internship programme and this caused many issues …” The participants also said the management was very poor in terms of supervision, feedback and duty roster. One participant said, “…we do not have proper supervision, clinical instructor and feedback system and the duty roster was made by technicians …”
The sixth category was ‘Gap in the System’.
The participants pointed out certain drawbacks in the system related to NNGs, such as unavailability of resources and poor supervision, lack of job description and suppression by doctors, failure of the Pakistan Nursing Council (PNC) in terms of accountability and lack of proper orientation programme. A participant said, “…Things were not like what we studied in college… the standard was low ...” Another participant said, “…they tried to highlight our mistakes in front of others in order to degrade us …” Most of the participants felt being pressurised by the doctors due to lack of job description. One participant said, “… nurses are too much suppressed by doctors in terms of their basic rights…”
The participants also expressed their thoughts about role of PNC related to NNGs. One participant said, “… I am disappointed by the PNC as it does not make the institutions accountable …” The last and most challenging issue perceived by the NNGswas lack of internship programme during the initial phase of the career. One participant said, “... we do not have any orientation or guidance programme...”.
The second theme was ‘Coping Strategies’ which noted how the NNGsput up with various pressures during the internship programme.
The first category under the theme was ‘Avoiding Harsh Behaviour’. Staying away from senior health workers was one of the common strategies used by NNGs for preventing conflict on the clinical side. One participant said, “…I used to be quiet and did not answer back, which was very important for moving forward…”
The second category was ‘Adjustment to Circumstances’, which is one of the vital features in one’s career during the initial stage of the learning process. One participant said, “…we gave them respect and used to be silent, and patience is very important for a bright future…”
The third category was ‘Support from Family, Teachers and Friends’. Self-support and motivation from family, teachers as well friends were the most important components for NNGs to cope with challenges. One participant said, “…I was about to leave the profession, but my sister and parents told me to prove myself ...” Another participant added, “…I supported myself and tolerated everything …we used to share things with our friends and teachers …”
The fourth category was ‘Hoping for Better Future’. Being hopeful helped the NNGs to move on and perform better for proving themselves. Most of the participants were hopeful that one day they will be accepted by their seniors and other health workers in terms of respect and graduates. One participant said, “…we tolerated our seniors and other health workers so that they can accept us one day and respect us as graduates…”
The fifth category was ‘Following Teachers’ Instructions’. Teachers are always role models for their students. Some of the participants said they had fewer conflicts after taking guidance from teachers. One participant said, “… my teacher guided me and I controlled my anger, started obeying the seniors and this made my life easier than before…”
The sixth category was ‘Adopting the Environment’. The adaptation process proved to be useful for decreasing stress and making the environment favourable. The NNGs believed that acting according to the environment helped them to continue their internship. One participant said, “…sharing our problems with the seniors helped us to get oriented with the environment and perform our duty smoothly …”
The third theme was ‘Improved Knowledge’ which covered the participants’ perceptions regarding achievements during the internship.
The first category under the theme was ‘Learned Basic Skills’. In spite of multiple challenges during the internship, the participants believed they learned some important skills and became confident to some extent. One participant said, “…after a few months I got interested in clinical practice and became very confident …”
The second category was ‘Interest in Caring’. Some participants said that after the difficult initial days, they developed interest in helping the patients in terms of providing nursing services. One participant stated, “…patients suffer a lot in the hospitals and we have to help them in this complex healthcare system…”
The third category was ‘Adjustment to Clinical Practice’.
Most participants viewed that they adopted the nursing profession as a career after knowing the importance of nursing care. One participant said, “…after learning for a few months, I got oriented to the clinical practice and realised that it was a matter of human life and we should care very carefully because these patients need us…”
The fourth category was ‘Passion for Caring’. The participants said the nursing profession had become the passion of their lives, and they loved to care about patients holistically. A participant said, “… This is our life now and we have to learn better about caring for patients and making a difference in their lives…”
The fifth category was ‘Application of Theory into Practice’. The participants said they got a chance to decrease the gap between theory and practice by taking interest in performing basic skills and assisting other healthcare professionals in different procedures. One of the participants aid, “…we got a chance to apply theory into practice which improved our concepts and ideas…”
The sixth category was ‘Respect for Human Life’. Most participants said they respected human beings and were motivated to make their lives better.
The fourth, and the last, theme was ‘Need for Improvement in Internship Programme’, which covered the perceptions of the NNGs towards the improvement of the internship programme.
The first category under the theme was ‘Modern Needs’. Most participants viewed that institutions and organisations needed to be equipped with certain characteristics, such as maintaining standards, professionalism, teachers’ involvement, availability of clinical instructors, management of resources and evaluation. One participant said, “…everything should be according to PNC and international nursing policies in practical form …” The participants agreed that their seniors along with society should respect them instead of demoralising them for no reason. One participant said, “…we are just novices and they must deal with us like their own children in a professional way…” Most of the participants recommended that the involvement of teachers and clinical instructors in the internship programme can play a vital role. One participant said, “…teachers need to play their role in guidance, motivation and roster-making as per competencies…we need qualified clinical instructors with a decent ratio …” The management of resources and proper feedback system for NNGs can be useful in carrying out their activities on a daily basis. One of the participants said, “…a simulation skills lab is important both in college and hospital for practical work …” Another participant said, “…we are required to have proper feedback so that we can know about our strengths and weaknesses …”
The second category was ‘Suggestions for NNGs’. The participants stressed on professionalism and selection of institution during the initial stage of their careers in terms of respect and punctuality. One of the participants said, “…respect your seniors and avoid quarrelling with them and you should be humble and punctual…” Another one said, “…some of the institutions in Pakistan are of good standard with excellent clinical facilitation and that makes you very confident…good organisations give you multiple opportunities…”
The third category was ‘Proper Orientation Programme’.
Awareness and orientation are the key elements for the success of any programme. One participant said, “…orientation programme is very important for NNGs …we have to know the environment and resources before starting our duties…”
The fourth category was ‘Continuous Struggle’. Hard work can beat talent and ensure success for people with vision. The participants believed that NNGs were required to be well-prepared theoretically and practically. One participant said, “…apply your theory to skills and be prepared both physically and mentally for serving this profession and work hard …”
The fifth category was ‘Institutional Efforts’. The higher management has important responsibilities and power that can be very beneficial for bringing about a positive change. The NNGs said director and teachers can improve the internship programme and their participation is very important for future nurses. One participant said, “… director and teachers can implement the policies and help the NNGs in achieving their goals...it is the best way to do it and motivation as well as appreciation should be given to the NNGs …”
The sixth category was ‘Implementation Strategies’. The participants enumerated certain strategies to implement rules and regulations regarding the internship programme. These included guidance, competency-based assignment and avoiding strictness. One participant said, “…cooperation and support from supervisors, teachers and clinical instructors is extremely important for us… as we are new in this profession…” According to the participants, duties should be assigned in different units as per performance and competence of the NNGs, having equal chance for rotation. A participant said, “… duties must be assigned by our teachers as per competencies of each NNG...” Another participant said, “…we are just like students now and they must have flexibility for us…we do not have experience and we should not be treated as experienced senior nurses…”
The study explored the experience of NNGs and detected certain challenges that were mainly individual or organisational. These difficulties had a negative effect on nurses, healthcare teams, patients and society. A study in 2016 reported similar challenges and concluded that the future of fresh nurses was being ignored.14 The current study showed that participants had certain individual challenges, and these findings were parallel to a previous study.15 In contrast, a study showed that NNGs had better performance and incraesed level of satisfaction due to regular interaction with their clinical instructors.16
The subjects in thecurrent study also reported challneges related to society, and similar findings have been reported earlier.17 However, one study reported that the NNGs received support from family, friends, organisations and community.18
The participants also pointed out issues related to organisation, and the existing literature supports such findings.19-21
In contrast, a study reported that in spite of the challenges, most NNGs were satisfied with clinical practice during internship and had a positive attitude towards their progress.22
In spite of multiple challenges, the participants in the current study developed certain coping strategies in order to avoid conflicts and focus on their internship goals. These findings are consistent with an earlier study23 but in contrast to another study which showed that the nurses were unable to solve the problems and to perform competently while delivering their services during clinical practice.24
The participants in the current study also perceived that internship was extremely important for NNGs in terms of orientation, improving competency and gaining confidence to apply theory being learned in the classroom. This is in kine with a study done previously.25 However, another study stated that the NNGs were unable to achieve internship goals and to continue their job because of multiple challenges, and immediate actions were required to overcome those hurdles.26
The participants in the current study identified certain areas for improvement related to the internship programme. Similar findings have been reported earlier.27In addition, proper communication is required between the teachers and hospital administration for better training and competency among NNGs in order to improve the future of nurses.28
The nursing profession in Pakistan is moving towards improvement, and the seniors are trying to deliver their best in this regard. The extracted categories and themes in the current study may notify the nursing leaders and health authorities about the needs of NNGs during internships. Policies and proper implementation should be planned to overcome these challenges. Continuous training, empowerment and motivation are the elements that may help the NNGs to have a positive image and bright future.
Internship is the most important phase for the professional development of NNGs. Certain individual and organisational challenges need to be overcome by the NNGs to become a part of the complex healthcare system.
Acknowledgements: We are grateful to the Prime Foundation, Pakistan, for facilitation and unconditional support.
Conflict of Interest: None.
Source of Funding: None.
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