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J Korean Acad Fundam Nurs > Volume 29(1); 2022 > Article
Doo, Seo, and Kim: New Nurses' Work Adaptation Experience

Abstract

Purpose

This study aimed to explore the work adaptation experiences of new nurses who underwent stress while transitioning into the workforce.

Methods

In-depth semi-structured group and individual interviews were conducted with 18 nurses working at a general hospital from December 2018 to February 2019. Colaizzi's phenomenological approach was followed for the data analysis.

Results

Four clusters of themes were drawn from meaningful data regarding the nurses' adaptation experience: “Weakened mind and body”, “Reaching one's mental and physical limits”, “Fighting back against work stress”, and “Assuming the role of a nurse”. The new nurses were the most stressed during the three to six months following independence from the preceptor, and after seven months on the job, they experienced some resolution by adapting to human relationships with their colleagues.

Conclusions

This study suggests a broad and longer perspective to which new nurses need to adapt, both at work and in human relationships, to overcome their difficulties.

INTRODUCTION

The shortage of trained nurses is a global concern, and new nurses are the most important human resources to fill this gap [1]. According to the 2019 hospital nursing staff assignment status survey, 45.5% of new nurses in 2018 left within one year, which is three times higher than the general average turnover rate for nurses of 15.4% [2]. Like-wise, in North America, 33.6% of new nurses quit their jobs within one year of hire [3], and in Taiwan, the turnover rate is highest within three months of beginning employment at 32.1% [4]. Thus, there is a need to effectively diagnose the challenges to sustaining new nurses in their chosen profession.
New nurses struggle to meet the expectations placed on them upon shifting their roles from university students to nurses and experience an overwhelming workload and anxiety [5]. Additionally, they experience the shock of the reality of difficulties in establishing interpersonal relationships with other professionals [6] and the difference between school learning and clinical practice; moreover, they face emotional stress [7,8]. More than 90% of nurse managers claim that new university-qualified nurses are not ready to perform safe and efficient patient care [4], indicating that they lack the necessary knowledge and competency for professional nursing work. In nursing departments, internships, preceptorship programs, and mentoring programs are all offered as preparatory courses to help new nurses adapt to their work [9]. Generally, it takes eight to 12 months for a new nurse to overcome the reality shock and adapt to their profession [10]. As a result of providing three to six months of orientation and preceptorship programs to new nurses in Canada, the preceptors could place new nurses in a comfortable space, and this safe learning environment provides new nurses with a positive experience [11]. However, according to a study of 89 hospitals in Korea [12], the average training period for newly graduated nurses in Korea was only 57.3 days, whereas three to six months (90∼180 days) post-beginning employment was shown to be a period of extreme stress for new nurses during which they have a strong inclination to change professions [4]. Therefore, we concluded that the supportive training period for new Korean nurses is insufficient.
An exploration of the process by which new nurses adapt to their new jobs in the hospital environment in Korea following an insufficient training period is valuable. In previously reported qualitative studies on new Korean nurses, nurses with different levels of work experience were evaluated. Studies assessed the experiences of nurses with 12 to 18 months of work experience during their first year [7], the experiences of those who moved to different hospitals within their first year of work [13], and the hospital work experiences of new nurses with less than four months of work experience [14]. The common difficulties of new nurses, as reported in these studies, included insupportable psychological and physical burdens due to a reality shock. As such, previous research included studies exploring the work-related challenges experienced by new nurses [15] and those focusing on the outcomes of new nurses adapting to their jobs [16,17]. Moreover, there is a dearth of studies exploring the process by which nurses both experience and survive such challenges. Therefore, this study applies a qualitative approach using the phenomenological method developed by Colaizzi [18] to explore new nurses' experiences as they adapt to the difficulties of their work. Colaizzi proposes that a vivid description of the experience of phenomena and contacts in life can facilitate understanding the essential structure and meaning of human experience. Thus, this study aims to use the perspectives of new nurses through individual and group interviews, ultimately generating exhaustive descriptions for analysis.
This study explores in depth the difficulties faced by new nurses as they initially adapt to their professional work. Through this exploration, we intend to provide preliminary data for the development of strategies to prevent job turnover and premature burnout among new nurses. The principal question raised by this study is, “What is the meaning of the experience for new nurses during the process of adapting to their professional work?”

METHODS

1. Research Design

This is a qualitative study that uses the phenomenological method developed by Colaizzi [18] and aims to explore the essence of new nurses' experiences in adapting to clinical practice.

2. Participants

This study involved three group interviews and eight individual interviews with a total of 18 nurses with less than one year of clinical experience chosen from among 103 possible nurses working at a general hospital with 500 or more beds in Goyang-si, Gyeonggi-do, using a convenience sample. For the selection of participants, a purposeful sampling method was employed in consideration of experience and department, and interviews were conducted when all participants agreed to participate voluntarily after receiving an explanation of the study. The group interviews consisted of participants who worked in similar working environments, which we considered to have ho-mogeneous attributes. The first group was divided into three people working in the intensive care unit; the second group included three people working in the comprehensive nursing care unit; and the third group included four people working in the emergency room, emergency intensive care unit, and emergency ward. Group interviews were conducted three times. As the depth to which the challenges of new nurses were expressed was limited in the group interviews, face-to-face individual interviews were also conducted with participants who were not included in the group interviews. The respondents participated in group and individual interviews until data saturation was reached, at which point no new concepts could be extracted.
The participants were 18 women who were unmarried. The average age was 23.0 years, and the age distribution ranged from 22 to 26 years. In terms of departments, three participants worked in the emergency room, four in the general ward, three in the comprehensive nursing care unit, seven in the intensive care unit, and one in the operating room. All participants held a bachelor's degree, and the average clinical experience was 8.28 months (range: 3∼11 months). The preceptorship program for new nurses in this research hospital lasted two months. Therefore, our participants had all successfully completed their preceptorship program.

3. Data Collection

Data were collected from December 27, 2018, to February 3, 2019. Interviews were conducted in conference rooms or breakaway rooms at the end of the participants'shifts to ensure privacy and convenience. The interviews commenced with general conversations about daily life to put the participants at ease and to encourage them to ex-press their experiences in a spontaneous way. The interviews were conducted by the second author of this study, who had previous experience with qualitative research, worked in a different institution from the participants, and had no acquaintance with any of them. Semi-structured questions were asked during both the group and individual interviews. Examples include “What difficulties have you encountered while working in clinical practice?,” “How did you adapt to the difficulties?,” and “What meaning did these experiences give you?” The interviewer asked the appropriate follow-up questions based on their responses. On certain occasions, additional questions, such as “Could you elaborate what you' ve just said?,” were asked to clarify or supplement responses. The interviewer directly recorded any observations, including fa-cial expressions, tone, and participants' behavior, and not-ed her personal thoughts regarding the participants. The group interviews lasted an average of two hours, and the individual interviews lasted approximately 90 minutes. Data were analyzed after the first interview to determine the content of and additional questions for the second interview. Data collection and analysis were performed concurrently. The second interview was conducted via e-mail or phone calls with eight individual interviewees. Interviews were terminated after the third group interview and the 16th individual interview, at which point the participants' stories became repetitive or no new stories and information were shared. All interviews were recorded with the participants' consent and transcribed verbatim.

4. Ethical Considerations

This study was approved by the institutional review board of the researcher's medical institution (IRB No. MJH 2018-12-012). The researcher obtained informed consent from the participants after explaining the purpose and method of the study, voluntary participation, anonymity, and participants' right to withdraw at any time. Additionally, it was announced to the participants that the interview would be transcribed after being recorded, that it would not be used for any purpose other than research, and that there was a possibility of publication.

5. Data Analysis

Data were analyzed using Colaizzi's analytical method [18]. First, the researchers read and reread the transcribed interviews to acquire an overall outline. Second, through a line-by-line analysis, significant statements were extracted from the transcribed data, while the researchers under-lined potentially essential content. Third, more general and abstract statements were formed by comparison of the significant statements. Fourth, formulated meanings were grouped into higher-level themes, such as sub-themes, themes, and clusters of themes, by continuously comparing the themes' similarities and differences. During the analysis process, the researchers exchanged opinions and held several discussions until a consensus was reached. Fifth, each theme was integrated into an exhaustive description through a continuous analysis and refining process. Finally, the researchers identified the general structure through an exhaustive analysis of the generally adaptive experiences of new nurses.

6. Rigor

To ensure the rigor of the qualitative data, it was evaluated based on four aspects, credibility, transferability, dependability, and confirmability, as suggested by Lincoln and Guba [19]. For credibility, the homogeneity of the study participants was increased, and the analysis process was performed six times with three qualitative researchers during data analysis. The results were then presented to three participants to confirm whether they were consistent with their experiences. For transferability, data were collected until the participants' statements reached data saturation, at which point no new concepts were extracted, and the study results were reviewed by two new nurses who did not participate in this study directly. For dependability, the data were collected consistently by the researcher, and the analysis method of Colaizzi [18] was followed thoroughly. Finally, for confirmability, prior understanding, assumptions, and prejudices regarding the new nurse were recorded in the reflection log so that the researcher's experience would not create prejudice affecting the new picture being constructed.

RESULTS

1. Results of Qualitative Analysis

As a result of this study, a total of 39 sub-themes were derived from the significant meaningful statements regarding new nurses' experiences with work adaptation, and 11 themes and four theme clusters were ultimately derived (Table 1).
Table 1.
Work Adaptation Experience of New Nurses
Sub-themes Themes Clusters of themes
․ Difference between the content learned through textbooks and clinical practice Confusion due to differences between theory and practice Weakened mind and body
․ Different perspectives on patient care at schools and hospitals
․ School-based education revolving around theory and less around practice
․ Slow work speed due to unfamiliarity with preparation for examinations or treatments Feelings challenged due to lack of work experience  
․ Difficulty in communication due to failure to understand healthcare practitioners
․ Difficulty providing explanations for patients or caregivers
․ Frustration in not knowing what to prioritize
․ Being misunderstood as procrastinating by coworkers when laughing Emotionless face and loss of words  
․ Not being able to concentrate on work due to always being nervous about making mistakes
․ Becoming quieter and losing interest
․ Losing confidence and becoming quiet in the hospital Losing confidence Reaching one's mental and physical limits
․ Feeling a dislike toward having my name called
․ Reluctance to stand in front of others
․ Having incomplete knowledge Feeling that I have not improved and am going in circles  
․ Increasing mistakes over time
․ Being reprimanded for repeating the same mistake over and over again
․ Unable to eat due to feelings of frustration
․ Difficulty sleeping while thinking about work
․ Feeling incompetent as a nurse Standing at a dead end
․ Developing a dislike toward people and accumulating negative emotions
․ Refusing to form new relationships
․ Reaching out to authority as a final resort
․ Beginning to perform tasks according to standardized protocols Standardized according to the frame Fighting back against work stress
․ Relying on manuals or instructions rather than asking a colleague
․ Behaving in a manner similar to senior nurses
․ Sharing and listening to challenging tasks with colleagues Changes in interpersonal relationships through socialization
․ Gaining positive energy through praise
․ Being able to tell colleagues thoughts I used to hide from others
․ Being able to laugh while talking to colleagues after work
․ Becoming comfortable enough with colleagues to ask for help
․ Learning to be cautious through mistakes Tolerance builds peace of mind
․ Handing over cases as if telling a story
․ Working with composure even when overloaded
․ Understanding the entire situation while adhering to protocols Expanding their boundaries Assuming the role of a nurse
․ Free enough to help busy colleagues
․ Not feeling burdened by expressing feelings in relationships with colleagues
․ Gaining confidence to overcome challenges Development of self-esteem
․ Feeling a sense of responsibility for my role
․ Having a desire to be a good mentor to younger nurses

1) Weakened mind and body

The “weakened mind and body” was an experience that most participants had during the first three months of work. Three themes were derived: “confusion due to differences between theory and practice”, “feeling challenged due to lack of work experience”, and “emotionless face and loss of words”.

Confusion due to differences between theory and practice

Most participants experienced confusion because the content and medical terminology they learned at university differed from the tasks performed in actual clinical settings, which was an unexpected experience for them. Content similar to practice sessions at university was ad-dressed step-by-step; nevertheless, the participants struggled to solve the same problems in the clinical setting and thus felt that they had to learn everything from scratch one-on-one with preceptor nurses. They also encountered more difficulties when assigned to special departments, such as the operating room, for which they had never received training.
It is difficult to define how the work differs from what I had learned in school. Nevertheless, there was much to learn at work. We learned many basic skills when we were in school; however, that was practice… at work, I had to insert the Foley catheter, and perform suction on unconscious patients. This felt completely different from what I had learned in university. – Individual 4
There were differences in the core skills that I learned at university. We must always check the position of the L-tube with a syringe before feeding. However, in clinical practice, this procedure is skipped. For medical terminology, we mainly learned about the diagnosis terms in school. At work, we mostly use the names of surgeries rather than diagnoses. Therefore, the terminology that we learned was not helpful. In school, when we were performing simulation practices, we had to measure vital signs and report any abnormalities to the attending nurse. However, now we know what really matters is what happens next. We have never learned the next steps. – Group 1

Feeling challenged due to lack of work experience

The participants were assigned independent tasks after the first two months of their work. However, they struggled to complete their tasks on time and often forgot those tasks, generating rebuke from senior nurses, which neg-atively impacted their confidence. They lacked knowledge and, therefore, experienced difficulties in providing ad-equate explanations for patients' conditions or the tests that the patients were undergoing. Some participants did not understand the content of the conversations between the patients and clinicians/senior nurses. Most importantly, they responded poorly when required to decide the next steps in emergency cases or on busy days. New nurses do eventually become independent, but they are physically and mentally exhausted by the process.
I did not know what to do in an emergency, and I was afraid that emergencies would happen. The doctors and senior nurses helped me a lot, but it was very stressful. – Individual 7
Even after becoming independent, I could not ac-curately answer the questions that arose when patients underwent surgery or treatment. I was extremely embarrassed as I had not received training, and could not provide explanations. – Group 3

Emotionless faces and loss of words

The participants shared that they chose not to talk to their colleagues during shifts or even smile, which they felt may have given the impression that they were not taking their duties seriously. Any jollity could also be viewed as interfering with their performance. The participants noticed that they became nervous and speechless because of their fear of making mistakes, and their faces became emotionless, causing them to be concerned.
I have to smile when dealing with patients, but I am worried that if I smile while working, I will make a mistake. So, the expression disappears. – Individual 6
In the wards, I feel nervous; therefore, my face ap-pears emotionless. I have noticed that other nurses also behave similarly. When I am extremely busy, I begin to frown without being aware of it. I worry that the impression I make will be affected unless I make an effort to change this. – Individual 1

2) Reaching one's mental and physical limits

“Reaching one's mental and physical limits” was an experience that participants had within three to six months of beginning employment. Three themes were derived: “losing confidence”, “feeling that I have not improved and am going in circles”, and “standing at a dead end.”

Losing confidence

Most participants began to hate going to work and felt sorry for themselves, as they had transformed into a different person at work. They seemed to have lost their previous bright personality, their previously confident voice and volume, and they were upset and felt ashamed if their performance did not meet their standards. One participant stated that she was scared to even hear the senior nurses call her name and felt disappointed with herself.
Many people around me had asked about my loss of confidence. I believed that I had lost the person I was before. When I worked with a strict nurse, my voice became softer and less confident. I was quite depressed… the problem was that I had begun to hate myself. – Individual 8
If someone called my name, I felt that I must have made an error. Occasionally, I feel hatred when I am called by name; it makes me believe that the only reason to call me is because something went wrong. – Group 3

Feeling that I have not improved and am going in circles

Six months following their hire, even when the participants appeared to have adapted to their work, they still did not know exactly what to do in difficult situations. They seemed to make more mistakes than before and felt that they were regressing rather than progressing professionally. Their repeated mistakes and consequent reprimands from senior nurses lowered their self-confidence even further, and they experienced physical symptoms such as anorexia, insomnia, and headaches.
I wondered whether my development had been stunted because I was unable to keep up with work. It was difficult and truthfully… I was slightly exhausted. I felt that I was nearing the end of my tether. – Individual 2
I felt uncomfortable even at home. I was unable to sleep, or breathe. My body had started to shake, and I experienced sudden headaches. Later, I began to feel pain in my heart. – Group 2

Standing at a dead end

The participants felt self-pity and expressed their concerns and conflicts regarding whether they were truly destined to be nurses; if they felt they were not, that is when they would resign. Some participants sought comfort from others, as they thought their current condition would not heal over time. Others contemplated resignations and career changes.
I felt that I could not continue, and that I was the worst nurse in the hospital. I also felt like an inadequate person. Additionally, I seriously considered whether the service I was providing was helpful, or I should quit. – Group 1
I thought that I should wait and quit after October. I found the job extremely difficult and thought that I would let my manager know about my decision to quit. Although I found it difficult to meet a manager (or chief), I arranged a meeting. However, during the meeting, I felt like my manager was listening to my experiences and issues. Then, it was a little … perhaps that indicated an opportunity, and I hoped that they would put me on rotation. – Individual 7

3) Fighting back against work stress

The “Fighting back against work stress” was an experience that participants went through after seven to nine months of work. Three themes were derived: “standardized according to the frame”, “changes in interpersonal relationships through socialization”, and “tolerance builds peace of mind”.

Standardized according to the frame

First, the new nurses did not meet the expected standards of work as they were in a rush to complete their assigned tasks. However, after trial and error, they checked their manuals or guidelines and performed their work according to the procedures. In addition, they imitated the work and actions of preceptor nurses, reflecting on the meaning of their actions. Although they did not have extra time to pay attention to their surroundings, as they focused on their assigned tasks without the help of preceptor nurses or senior nurses, they performed their work within the orthodox work time and way, following the manuals or guidelines until they felt they had adapted.
On numerous occasions, I found myself rushing to complete tasks independently; however, this led to more mistakes. Now, I first look up diagnosis names on the Internet, check the computer screen to confirm if I have to prepare anything for tests, and then follow the pocketbook or manuals. – Individual 3
Initially, when I started my job, I used to be busy copying what the preceptor nurse did instead of trying to learn, think, and reason through the tasks. Then, when I had to perform the tasks independently, I could not do anything. That was when I realized the importance of consulting manuals. – Individual 4

Changes in interpersonal relationships through socialization

The participants shared their experiences with their colleagues. They realized that they had experienced the same difficulties. Most participants shared their feelings and were comfortable with each other. When necessary, they sought help from senior nurses or colleagues. They felt a sense of relief after completing their tasks and were able to laugh about their professional difficulties during post-shift conversations with senior nurses. They responded that they felt close to their colleagues and other nurses, as if they were family members and that even in such a difficult work environment, they received positivity from their role models-the preceptor nurses – and the friendly faces of their peers.
After work, my colleagues and I go out to eat dinner or drink coffee and talk. This helps me relieve stress, though we do not do anything special. – Individual 1
I use Kakao Talk with my colleagues. We share our experiences at work. I feel that I am not the only one struggling, and I am comforted. – Individual 2

Tolerance builds peace of mind

Mistakes made the participants cautious, and they were able to perform their tasks efficiently only as they became more experienced. They began to maintain their composure and organized work according to their priorities. One participant compared the feeling of walking on a street lit by a faint moonlight, which is not as bright as a street lit by a streetlight.
Today, as I was handing work over to my replace-ment, I was talking like we talk about something com-monplace. I think now I am able to discuss my daily life without stress. Once the handover was completed, the charge nurse said, “Great job today.” I felt, “I finished my job on time,” which makes me feel good. – Group 1
I'm used to the job. It's not perfect, but I'm aware of it. If you don't panic when you're busy and organize your work according to your priorities, it will be completed at some point. Now, I am equanimeous even when overloaded with work. – Group 3

4) Assuming the role of a nurse

“Assuming the role of a nurse” was an experience that participants acquired after more than nine months at work. Two themes were derived: “expanding their boundaries” and “development of self-esteem”.

Expanding their boundaries

The participants felt proud of their skilled performance in the assigned tasks and their capacity to help their colleagues. As they acquired equanimity, they could objectively observe a situation separately from following the task guidelines. They were interested in the work of other nurses and felt proud after receiving compliments or being acknowledged by senior nurses. Additionally, they were steadily surpassing expectations by constantly challenging themselves and achieving daily goals to become better professionals.
I always received help from senior nurses. However, I am sometimes able to help with them. If senior nurses are busy, I go and help, even without being asked for help. At the end of the shift, they say “thank you”, and I feel good and proud that I could help. – Individual 6
It has been nine months at this job. Nowadays, I observe the patients a little more, and I am more sensitive to their face color. Patients with digestive problems bleed significantly. Therefore, they may be slightly unconscious, and their blood pressure may decrease, so I talk to them just to check that they are okay, and I measure their blood pressure once more. – Individual 7

Development of self-esteem

The participants acknowledged their roles as nurses and realized their worth as they looked back at their experiences. They felt that they wanted to have a positive influence on others and desired to become respected senior nurses for their junior colleagues. Above all, the participants gained confidence that they could overcome difficulties and noticed the changed, more confident images that they projected to others.
In the past, I thought a lot about human relationships. Nowadays, I think about the kind of example I should set for junior nurses. I look back on my difficulties, and I tell myself, “I should teach them this in such cases”. – Individual 5
I think I am becoming the nurse that I believe I am, and I think I am making progress. It's different from when I first joined the company. I have gained the confidence to overcome challenges and it is good to see progress. – Group 1

2. Exhaustive Description of the Work Adaptation Experience of New Nurses

This study showed that the lack of work experience and interpersonal difficulties caused stress for new nurses. It changed their physical appearance and personality and left emotional scars that caused them to lose their confidence. Such experiences were comparable to physical and mental weakness, and reaching these limits left them feeling defeated, which led them to consider a career change. This was observed around the third month of work, after new nurses finished one-on-one training with preceptor nurses and became independent. They experienced frequent delays and mistakes at work, which made them feel embarrassed. They thus believed that they were not im-proving and were, in fact, deteriorating professionally. They endured these difficulties, attempting to solve their problems by reflecting upon their mistakes; however, they continued to contemplate career changes. After six months at work, they began to gain self-confidence through the habit of consulting manuals and guidelines for the assigned tasks. They internalized the meanings of the actions of their senior nurses, who were their role models. As they gradually adapted to their work environment after nine months on the job, they began to fully comprehend their work situation. They applied their knowledge and experience to care for their patients and maintained friendly relationships with and had a positive effect on their colleagues. Professional confidence was shown to be a prerequi-site for new nurses' work adaptation. Over time, self-confidence was accompanied by the comfort of human relationships, which signified adaptation in both work and personal spheres.

DISCUSSION

This study explored the work adaptation experience of new nurses with an average of 8.28 months of work experience in their new clinical setting. The results indicate that new nurses suffered the most during the first three to six months of independence from their preceptor. Moreover, they showed that after seven months on the job, new nurses began to experience work adaptation by forming authentic relationships with their colleagues.
The first work adaptation experience of new nurses was termed “Weakened mind and body.” The participants experienced psychological conflicts arising from stress and tension due to their inexperience and confusion, which was caused by the gap between the theories they learned in school and in-hospital clinical practice. Our findings were consistent with previous studies showing that new nurses experience disillusionment and shock as they face role conflicts because of the gap between the expectations and realities of their work [20]. In other countries, a sub-stantial orientation period is considered important for facilitating new nurses' smooth adaptation to their work environment [21,22]. This suggests that the two-month ori-entation period for new nurses observed in our sample was insufficient. In Korea, an educational nurse support project-limited to national and public hospitals and integrated nursing care wards-is offered. However, this project is still in its early stages. In general, after the two-month training period, most new nurses are expected to perform their tasks independently. Therefore, it is necessary to secure more educational-teaching nurses to minimize the workload of new nurses and help them adapt more smoothly to the realities of actual clinical practice. Moreover, a previous study [23] conducted in three nursing colleges in the United States may be useful as a refreence to establish a connection between school educationa and clinical nursing practice. In this study, clinical nurses imparted clinical practice education to groups of six to seven nursing students to inform them of the latest clinical practice-oriented nursing interventions. Additionally, as revealed in our study, the new nurses experienced difficulties because of inadequate work experience in special departments and possessing theoretical knowledge that was not applicable in the real world. Kim [14] also reported that school education was not helpful for learning nursing work in special departments, in accordance with our findings. For nursing students in their final year of school, strategies to offer clinical practice in the desired department to improve adaptability and work capacity should be considered. Additionally, a small portion of clinical practice can be replaced with simulation-based education or virtual reality simulation practices.
The second theme cluster was termed “Reaching one's mental and physical limits”. The participants exhibited decreased self-confidence owing to a repetition of mistakes and subsequent reprimands from senior nurses. Such experiences engendered symptoms of anorexia, insomnia, and headaches. This was mainly observed in the first three to six months of work. New nurses lost their self-identity and contemplated a career change. These findings are in line with the results of previous studies that suggest that self-confidence and work satisfaction decrease in new nurses [24,25] because of frequent work-related mistakes [26,27]. Moreover, a negative relationship with senior nurses, upon whom they are reliant, imparts a sense of betrayal, leading to feelings of hatred and sadness [20]. Therefore, it is understandable that Cheng et al. [4] reported that new nurses with three to six months of work experience have a high intention of changing careers. Furthermore, Duchscher [28] suggested that new nurses are prone to experi-encing negative emotions such as self-doubt, anxiety, in-security, and lack of confidence in the beginning of their careers. This is because during this time, they are more likely to experience significant changes in aspects of responsibility, character, knowledge, and interpersonal relationships. Therefore, during the transition period as new nurses adapt to their work, continuous interest and support are required on the part of hospitals. As part of the strategy suggested by Lyu et al. [29], to enable new nurses to overcome physical and mental challenges, specific behavioral programs involving factors such as increasing optimism, building confidence, and expressing negative emotions are needed. Conversely, some new nurses sought a transfer to other departments to escape their difficult situation. Ishihara et al. [30] reported a similar finding, suggesting that nursing managers could reduce the rate of turnover of new nurses. It is thus important for nurse managers to show particular interest in new nurses with less than six months of work experience and to continuously monitor their progress through interviews and meetings.
The third theme cluster was termed “Fighting back against work stress.” As the new nurses adapted to their tasks after approximately seven months on the job, they gained confidence in their work. Our results show that the new nurses adapted as they endured and reflected upon improvement in their work difficulties. Consistent with this finding, in a previous study, new nurses gradually showed improved work performance and comfort as they adapted to the hospital environment [15]. In other words, repeated mistakes and forgetting assigned tasks during the early stages of work, when they become independent following their training with preceptor nurses, indicated that new nurses were not used to checking work standards or evidence because they were shadowing and relying on preceptor nurses. Moreover, the participants confessed feeling lost when overwhelmed with work. This suggests that they were hard-pressed to consult manuals or guidelines. Therefore, in addition to providing oral instructions, it is thought that the role of senior nurses in guiding the procedures and evidence in a step-by-step manner is important.
In our study, it was also observed that encouragement and acknowledgment from senior nurses as well as encouragement from colleagues helped new nurses develop a sense of belonging to the organization and led to positive changes in interpersonal relationships. Lee et al. [7] reported that new nurses understood and comforted each other through their interactions and became each other's source of support. Accordingly, they adapted to their tasks, checked the manuals and guidelines for proper care, and encouraged their colleagues to develop a sense of belonging to the organization.
The fourth theme cluster was termed “Assuming the role of a nurse”. As the participants skillfully adapted to their tasks, they were able to objectively observe the overall situation, and their equanimity had a positive influence on their colleagues. In accordance with our findings, Ke and Stocker [20] reported that new nurses formed human relationships during the process of adapting to their profession, gradually finding their place in the clinical setting. As shown in our study, the first year as a new nurse is an unstable period until nurses adapt to their new work environment [15]. Over time, they exhibit an increased capacity for work and a desire to become a good mentor for inexperienced nurses. These findings are consistent with previous results [25,26], in which new nurses were shown to acquire self-confidence through both negative and positive experiences in nursing work. As such, most new nurses overcame their work difficulties and began to adapt to their new roles over time. However, nurses within the first three to six months of employment are still in the transitional stage in terms of acquiring their roles, suggesting the need for various transitional programs to provide opportunities and information to support their growth.
The significance of this study is threefold. First, to reduce the gap between theoretical education in school and actual clinical practice, nursing experts should participate in curriculum design to reflect field-oriented education. Next, to help new nurses adapt to their work, the educational nurse support project should be expanded through realistic consideration of nurses' orientation period and support needs. In particular, nurse managers and senior nurses must carefully observe new nurses during the first three to six months, particularly when they become independent. They must support these new nurses through praise, recognition, and consideration rather than reprimands to establish an all-round positive work environment. Finally, this study is meaningful as it provides evidence-based results for specific cases, which can be used for training new or preceptor nurses in the future. However, this study has limitations in generalizing the study results as the participants were all women and recruited from a single hospital.

CONCLUSION

This study investigated the meaning and essence of the experience of overcoming the difficulties faced by new nurses during their adaptation to clinical settings using the phenomenological method described by Colaizzi [18]. It was observed that nurse managers and senior nurses should carefully supervise new nurses when they begin to work independently, lend support, and set examples for them to follow. Additionally, a cooperative and motivating organizational environment for new nurses was shown to be important. New nurses need time to reflect upon their mistakes and undergo significant challenges as they adapt to their work environment. These findings suggest that new nurses need to adapt to both work conditions and human relationships to overcome their difficulties. Based on these findings, future studies are necessary to understand how new nurses gain self-confidence in their work. Furthermore, we suggest studies on such interventions at the organizational level that can facilitate the forging of positive and successful human relationships during new nurses' early experiences.

Declaration of Conflicting Interests

CONFLICTS OF INTEREST
The authors declared no conflict of interest.

Notes

AUTHORSHIP
Study conception and design acquisition – DE-Y and SH-E; Data collection – DE-Y and SH-E; Data analysis & Interpretation – DE-Y and KM; Drafting & Revision of the manuscript – DE-Y and KM.

REFERENCES

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