Professional development among newly graduated registered nurses working in acute care hospital settings: A qualitative explorative study

Abstract Aim To explore newly graduated registered nurses' perceptions of their work situation and management of nursing care in complex patient situations after 18 months of work experience. Background Newly graduated registered nurses working in acute care hospital settings play a critical role in providing safe nursing care. Methods An explorative qualitative design, with four focus group interviews with 14 newly graduated registered nurses working in acute care hospital settings. Results One theme emerged: ‘Clarity and security in one's own nursing role despite facing challenges that hinder professional development’ and three categories: ‘Independency due to one's own efforts and experience’, ‘Well‐functioning teamwork’ and ‘Challenges in the work situation’. Conclusion After 18 months in the profession, the nurses were considered to be advanced beginners; at the same time, the most experienced nurses on their respective wards. They found it challenging and need to further develop competences concerning managing and organizing the nursing care of several complex patient situations or new patient groups, as well as supervising novice registered nurses and nursing students. Implication for Nursing Management Powerful and urgent action is needed to be taken by national healthcare policymakers as well a hospital and nurse managers to develop long‐term strategies to improve working conditions for newly registered graduated nurses.


| INTRODUCTION
Today's newly graduated registered nurses (NGRNs) who commence work in acute care hospital settings will face fast-changing healthcare systems that are characterized by an increasing number of patients with acute, chronic and complex co-morbidities (Hussein et al., 2017), shorter hospital lengths of stay (Buchan et al., 2013) and a shortage of registered nurses (RNs) (WHO, 2020c). This can lead to higher demands being placed on NGRNs who are expected to provide comprehensive nursing care that meets patients' complex and diverse needs in acute care hospital settings (Bandini et al., 2018).

| BACKGROUND
RNs' competence is developed by gaining experience over time in conjunction with gaining theoretical knowledge and the ability to be reflective. RNs describe themselves being motivated to pursue professional development as it is a way to increase competence, comply with requirements, deepen knowledge and increase career possibilities (Falk & Lindström, 2022;Pool et al., 2016). For further professional development, teamwork (Eddy et al., 2016;Serafin et al., 2022) and leadership that supports teamwork and facilitates professional development are of importance (Page et al., 2020). WHO (2020a; 2020b) is also arguing for the importance of RNs' competence concerning leadership, which must be highlighted at all levels in healthcare organizations.
In recent years, acute care hospital settings have become increasingly specialized and complex (Disch et al., 2016), primarily due to the increasing number of patients who are in need of more demanding and complex nursing care in acute care hospitals (Carnesten et al., 2022;Dharmaraijan et al., 2016). Along with the heightened complexity of patient cases admitted to hospitals, there has also been a constant shortage of RNs (ICN, 2019), in particular of experienced RNs (National Board of Health and Welfare, 2018). Organizing healthcare without a sufficient number of RNs may lead to a decline in patient safety (Aiken et al., 2017;Driscoll et al., 2018), and patients in complex situations have been found to have a higher risk of mortality and lower probability of home discharge (Bandini et al., 2018).
Nursing care in complex patient situations are dynamic interactions related to instability, variability and uncertainty from the perspective of the patient and the RNs with processes such as personal, communication and cognitive, psychosocial and ethical aspects interacting with each other causing uncertainty and unpredictability in a situation (Huber et al., 2020;Kannampallil et al., 2011). In order to handle nursing care in complex patient situations successfully, RNs need professional experience, expertise and clinical reasoning skills, as well as contextual prerequisites such as time resources and support through teamwork (Kentischer et al., 2018). Previous studies on NGRNs have focused on their transition from education into professional life and describe them facing new demands and challenges in complex patient situations (Arrowsmith et al., 2016;Cheng et al., 2021;Walton et al., 2018) and that both organizational and personal factors influence their professional development (Charette et al., 2019). However, there is limited knowledge regarding NGRNs' perceptions of their working situation, how they manage nursing care in complex patient situations in demanding and complex acute care hospital settings after their first one and a half year in the profession.
What is the understanding of NGRNs about their work situation in nursing care in an acute care hospital? How does the careful management of inpatient nursing care for these patients occur? Therefore, the aim of the study was to explore NGRNs' perceptions of their work situation and management of nursing care in complex patient situations after 18 months of work experience.

| METHODS
An explorative qualitative design was used to gain a deeper understanding of a predetermined subject (Polit & Beck, 2021), and an inductive manifest and latent content analysis was performed as described by Krippendorff (2018). Data were collected through focus group interviews (FGIs) (Morgan, 1997). FGIs aim to access a deeper understanding of a predetermined subject as they allow participants to interact with each other and explore their perceptions, views and opinions using their one's own words (Morgan, 1997). In accordance to EQUATOR Network, the COREQ criteria for reporting was used (Data S1) (Tong et al., 2007).

| Context
Study participants consisted of NGRNs who were employed by a county council in central Sweden. The NGRNs worked in direct patient care in a central regional acute care hospital on a variety of wards including medical, surgical, emergency, gynaecological, psychiatric and oncological wards. In this study, the NGRNs are considered to be advanced beginners, due to RNs considering themselves to be novices or advanced beginners for their first 2 years of professional life (Benner, 2001).

| Sample and recruitment
The NGRNs who participated in this study were recruited using convenience sampling (Polit & Beck, 2021). They received oral and written information about the study at the beginning of their clinical development programme. The first author was assisted by a ward head nurse to gain access to eligible NGRNs who had 18 months of clinical experience. The first author contacted the participating NGRNs using telephone text messages to arrange the time and place for the FGIs. Prior to the FGIs, interested NGRNs received an information letter and provided written informed consent. In total, 14 NGRNs agreed to participate in the study. Their ages ranged between 24 and 30 (mean age 26.8 years), and 12 participants were women and two were men.

| Ethical considerations
Ethical considerations were made in accordance to the Helsinki Declaration (2013). Before each interview, informed consent was collected. They were also informed that participation was voluntary and that they were free to end their participation at any time without giving an explanation. The study was given ethical approval by the National Ethical Review Board.

| Data collection
As a point of departure, each FGI started off with a question asking participants to describe their understanding of complex patient situations related to instability, variability and uncertainty. The FGIs were conducted as semi-structured discussions and were based on a semi-structured interview guide (Table 1). In addition to the semistructured interview guide, follow-up questions were asked. They lasted between 43 and 62 min (mean 56 min) and were recorded and transcribed verbatim.

| Data analysis
The transcribed data were analysed using a text-driven, interpretive qualitative manifest and latent content analysis that included several steps (Krippendorff, 2018). The interviews were firstly read several times to get an overall understanding of the data. Thereafter, they were read thoroughly to identify manifest meaning units, which were used to formulate codes. At this stage of the analysis, data are based on manifest content that clearly emerge from the transcribed text. The codes were then grouped into subcategories based on similarities and differences. The contents in the subcategories were interpreted and sorted into latent categories. As the subcategories were built on manifest data, then more complex analyses and interpretations were made following 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 (Krippendorff, 2018). The authors then agreed on eight subcategories that the three categories are based upon, which then emerge in one overarching theme ( Table 2). The last step of the process was to confirm the relevance of the results by verifying the correlation with the aim and the categories and the overarching theme (Krippendorff, 2018).

| RESULTS
One overarching theme 'Clarity and security in one's own nursing role despite facing challenges that hinder professional development' and three categories emerged: 'Independency due to one's own efforts and experience', 'Well-functioning teamwork' and 'Challenges in the work situation' ( Table 3). The NGRNs perceived that they gained competence, independency and confidence in the nursing care of complex patient situations they had experience of, resulting in clarity and security in their role as an NGRN. They managed complex patient situations thought leading and collaborating with colleagues and patients. They found that facing challenges in the work situation reduced their ability to manage the nursing care of several complex patient situations simultaneously or complex patient situations they are not familiar with, such as patients who usually stay on other wards. These challenges were also perceived to be a hinder in their professional development.

| Independency due to one's own efforts and experience
After being in the profession for 18 months, the NGRN had gained experience of nursing in complex patient situations. Due to competence gained through experience and their one's own efforts along with struggles, they perceived that their professional competence had increased and that they had gained confidence and independency in the role as an RN. A common opinion was that experience gained through working as an RN along with a gained confidence and positive attitude had contributed to this and developed the ability to provide optimal nursing care in complex patient situations. They had also learnt how to prioritize different tasks and develop routines for tasks that they carried out repeatedly, and they had gained experience through handling several different complex patient situations in the acute care hospital settings they worked in.
… there was a patient who had a troublesome venous port and he did not want me to use it because it has bothered him so much, I said we should try … I think he felt I knew what I was doing and then it wasn't a problem, it probably has a lot to do with the attitude you put across …. I also feel that if you have better self-confidence, then things will work out well …. (FGI 1, P 2, P 4)

| Challenges in the work situation
Participating NGRNs perceived that their work situations were sometimes challenging as they perceived that they were given the responsi- is referring to RNs with 18 months in the profession as advanced beginners. As a consequence identified in the present study is that where there is high staff turnover of RNs, knowledge disappears from the wards and this is a threat to RNs' professional development. Earlier research has shown that a lack of peer support is a barrier to professional development (Page et al., 2020). Organizational support and strong nursing leaders play a vital role in RNs' professional development, for example, by moving away from traditional hierarchies and identifying individual RNs' clinical competence and need for further training (King et al., 2021). However, this presupposes that the manager has genuine knowledge in evidence base nursing care with the adequate level of education in order to be able to make right assessments and support each individual NGRN after 18 months within the profession.
These results reflect the consequences of the global nursing shortage (Buchan et al., 2013), which is estimated to increase in the The results of the present study show that one obstacle in achieving professional development among NGRNs was the uncertainty associated with supervising NGRNs with less experience in complex patient situations. Other studies have reported that novice RNs report low levels of competence in supervising students and staff (Gardulf et al., 2019;Nilsson et al., 2019) and in the organization of nursing care (Halabi et al., 2020). One possible way to support the transition and professional development in working in the context of acute care hospital settings among NGRNs has been shown to be peer learning (Pålsson et al., 2018). It is therefore of importance for ward managers to utilize research evidence when organizing teams in terms of RNs with different experience levels of overall competence in the health care team as recommended by the National Board of Health and Welfare (2015). Well-composed teams could increase RNs' job satisfaction and thus increase the chances of retention. It is the employer's responsibility to provide RNs with the conditions required to be able to carry out nursing care with high patient safety and good quality, as these are important predictors for wanting to remain in the profession.
Previous research shows that even RNs with approximately 5 years of experience find nursing in complex situations challenging or overwhelming (Kentischer et al., 2018). The participating NGRNs in the present study had the ability to manage the nursing care of single complex patient situations, but when presented with several cases simultaneously or complex patient situations they not were familiar with, they found it more difficult. The difficulties were related to managing the making of assessments and prioritizing and organizing care, and the NGRNs felt that they took a step back in their professional development as a consequence of these difficulties. It has been found that nursing in complex patient situations can lead to incomplete care or the avoidance of providing care, which can be a threat to patient safety, especially when under time pressure (Vinckx et al., 2018). To accomplish an effective nursing process in complex patient situations and the best outcome for the patient, the level of the RN's attention, knowledge and experience is crucial (Huber et al., 2020) as shown in this study among NGRNs' nursing care in single complex patient situations. Another strong incitement for NGRNs not being given sole responsibility for several complex patient situations simultaneously is that an association between the complexity of nursing care and turnover among NGRNs has been found (Ten Hoeve et al., 2020). Hence, it is not appropriate to make NGRNs responsible for leading a team, assessing, prioritizing and organizing care for several patients in complex situations or unfamiliar cases usually treated on other wards when they have only been in the profession for 18 months, due to the risk of increased turnover and reduced patient safety.

| Limitations
As suggested by Morgan (1997), a goal was to include FGIs with four to six participants; thus, this was not possible to organize. Despite there only were three participants in one FGI, they interacted well with each other and generated in richness of information as they shared their views, thoughts and opinions. FGIs aim to capture the interaction in the group to explore and discuss between the participants. The number of participants may also be seen as a limitation; however, saturation was discussed during the analysis process, and saturation was assessed to be reached after analysis of the fourth FGI. Using FGI was also a way to capture new knowledge. The head of the ward nurse recruited the participants; this could serve as a limitation as they might have asked the most positive NGRNs.

| CONCLUSION
NGRNs with 18 months of professional experience are considered to be advanced beginners; however, due to high turnover in the profession, they are among the most experienced RNs on their respective wards. Despite having developed independency and clarity in their nursing role as well as leadership skills, they were facing challenges that made their work situation difficult. This was due to managing and organizing the nursing care of several complex patient situations or new patient groups, and supervising novice RNs and student nurses is challenging, and they need further support to develop competencies in these areas.

| IMPLICATION FOR NURSING MANAGEMENT
Powerful and urgent action is needed at a national level by healthcare policymakers to develop long-term strategies to improve NGRN's working conditions. Further, it is the responsibility of the healthcare leaders and management to improving work conditions and professional growth among all RNs to ensure that staffing is adequate, with a mix of different experiences and competences. Retaining the more experienced RNs within patient-centred work the NGRNs would also benefit a security and role models. However, this presupposes that the manager has genuine knowledge in evidence base nursing care with the adequate level of education in order to be able to make right assessments and support each individual NGRN after 18 months with in the profession by developing long-term strategies for improving their work condition and by establishing adequate staffing combinations by considering RNs' different experience levels that will contribute to the total competence within the team. Further, RNs need to be given a position in the healthcare systems, so they can have an impact of RNs work situation and facilitate a sustainable working life.

ACKNOWLEDGEMENTS
We would like to thank all the newly graduated registered nurses who took their time and participated in the study.

CONFLICT OF INTEREST
The authors declare that they have no competing interests or conflict.

ETHICS STATEMENT
The study followed the ethical principles in accordance with the

DATA AVAILABILITY STATEMENT
Data are available, but not for public due to ethics.